Provider Demographics
NPI:1518382902
Name:GONZALES, GINA MARISSA
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARISSA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 BAY BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:TX
Mailing Address - Zip Code:77586-1671
Mailing Address - Country:US
Mailing Address - Phone:832-867-4011
Mailing Address - Fax:281-532-2079
Practice Address - Street 1:3406 BAY BREEZE DR
Practice Address - Street 2:
Practice Address - City:SEABROOK
Practice Address - State:TX
Practice Address - Zip Code:77586-1671
Practice Address - Country:US
Practice Address - Phone:832-867-4011
Practice Address - Fax:281-532-2079
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193400000X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services