Provider Demographics
NPI:1740859057
Name:GONZALEZ, LONI RAE
Entity type:Individual
Prefix:
First Name:LONI
Middle Name:RAE
Last Name:GONZALEZ
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 1:208 STARR ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-2736
Mailing Address - Country:US
Mailing Address - Phone:956-514-1551
Mailing Address - Fax:
Practice Address - Street 1:208 STARR ST STE 2
Practice Address - Street 2:
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-2736
Practice Address - Country:US
Practice Address - Phone:956-514-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118281235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118281OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION