Provider Demographics
NPI:1912671082
Name:GONZALEZ, ELIZABETH JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62243-1079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEBURG
Practice Address - State:IL
Practice Address - Zip Code:62243-1079
Practice Address - Country:US
Practice Address - Phone:618-314-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018029051225700000X
IL227006257225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist