Healthcare Provider Details

I. General information

NPI: 1700560778
Provider Name (Legal Business Name): CHRISTINA GONZALEZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 E ORANGEBURG AVE
MODESTO CA
95350-5334
US

IV. Provider business mailing address

2600 COMPASS RD
GLENVIEW IL
60026-8001
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-2811
  • Fax:
Mailing address:
  • Phone: 847-441-5593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: