Provider Demographics
NPI:1750538807
Name:GONZALES, IVYROSE (MOTR/L,ATC)
Entity type:Individual
Prefix:MS
First Name:IVYROSE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MOTR/L,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12105 DAN PATCH RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-2196
Mailing Address - Country:US
Mailing Address - Phone:505-350-3069
Mailing Address - Fax:505-508-2305
Practice Address - Street 1:2727 SAN PEDRO DR NE
Practice Address - Street 2:STE 116
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3364
Practice Address - Country:US
Practice Address - Phone:505-350-3069
Practice Address - Fax:505-508-2305
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NM0805225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93985312Medicaid
NMNMA101051Medicare PIN