Healthcare Provider Details

I. General information

NPI: 1710312459
Provider Name (Legal Business Name): TARA L GONZALEZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 SCARBOROUGH DR STE 200
COLORADO SPRINGS CO
80920-7513
US

IV. Provider business mailing address

13951 E 104TH DR
COMMERCE CITY CO
80022-9448
US

V. Phone/Fax

Practice location:
  • Phone: 719-630-7500
  • Fax:
Mailing address:
  • Phone: 352-422-6562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0012294
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: