Healthcare Provider Details

I. General information

NPI: 1013942770
Provider Name (Legal Business Name): LENNIS IVETTE GONZALEZ P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 N MAIN ST
BRANFORD CT
06405-3044
US

IV. Provider business mailing address

80 HORSE POND RD
MADISON CT
06443-2513
US

V. Phone/Fax

Practice location:
  • Phone: 203-481-0818
  • Fax: 203-483-9843
Mailing address:
  • Phone: 203-245-4509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003729
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: