Provider Demographics
NPI:1669785184
Name:GONZALES, ROXANNE L (SLPA)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:L
Last Name:GONZALES
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-3202
Mailing Address - Country:US
Mailing Address - Phone:214-971-5400
Mailing Address - Fax:
Practice Address - Street 1:1748 TOPAZ DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-5000
Practice Address - Country:US
Practice Address - Phone:970-800-3287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35547235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX456606Medicare UPIN
TX149984001Medicaid