Provider Demographics
NPI:1750960340
Name:GONZALEZ, CARON GEORGE (CMT)
Entity type:Individual
Prefix:
First Name:CARON
Middle Name:GEORGE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 AVIATION BLVD # 524
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2810
Mailing Address - Country:US
Mailing Address - Phone:718-541-9702
Mailing Address - Fax:
Practice Address - Street 1:2021 CARNEGIE LN APT 1
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3658
Practice Address - Country:US
Practice Address - Phone:718-541-9702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68743225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist