Provider Demographics
NPI:1700903366
Name:GONZALES, PAMELA R (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:R
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13610 BARRETT OFFICE DR.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63021
Mailing Address - Country:US
Mailing Address - Phone:314-941-2070
Mailing Address - Fax:314-822-5106
Practice Address - Street 1:13610 BARRETT OFFICE DR.
Practice Address - Street 2:SUITE 104
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63021
Practice Address - Country:US
Practice Address - Phone:314-941-2070
Practice Address - Fax:314-822-5106
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002004794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist