Basic Information
| Provider Information | |||||||||
| NPI: | 1952771537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3136 DEL MAR AVE | ||||||||
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| City: | ROSEMEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917702326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262888353 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8712 MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | ROSEMEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917701816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263786927 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2015 | ||||||||
| LastUpdateDate: | 09/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 3241 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.