Healthcare Provider Details

I. General information

NPI: 1477337368
Provider Name (Legal Business Name): MARIELA DIANA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15401 S MAIN ST
GARDENA CA
90248-2214
US

IV. Provider business mailing address

6060 CENTER DR FL 7
LOS ANGELES CA
90045-1596
US

V. Phone/Fax

Practice location:
  • Phone: 424-292-3260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number309392
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6623
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: