Basic Information
| Provider Information | |||||||||
| NPI: | 1841661337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | CASEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 ROSA AVE SW | ||||||||
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| City: | LOS LUNAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870318619 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5901 OURAY RD NW | ||||||||
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| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058360023 | ||||||||
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| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 3228 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.