MEDICARE: DENISE M GONZALES PTA-AIDE CMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	37810	CA

General Provider Information

NPI Number	:	1518369479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE M GONZALES PTA-AIDE CMT

Provider Business Mailing Address
First Line	:	10149 ALTA BRISA WAY
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92557-9019
Country	:	US
Telephone Number	:	818-602-9163
Fax Number	:

Provider Business Practice Location Address
First Line	:	10149 ALTA BRISA WAY
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92557-9019
Country	:	US
Telephone Number	:	818-602-9163
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	04/25/2021

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