Provider Demographics
NPI:1780317784
Name:GONZALEZ, AMY DOMINIQUE (DPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:DOMINIQUE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DOMINIQUE
Other - Last Name:FRANK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:8704A DESERT HOLLY PL SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87116-3222
Mailing Address - Country:US
Mailing Address - Phone:575-770-5542
Mailing Address - Fax:
Practice Address - Street 1:306 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4207
Practice Address - Country:US
Practice Address - Phone:575-835-8343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT6124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist