Healthcare Provider Details

I. General information

NPI: 1992220883
Provider Name (Legal Business Name): ELISSIA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 08/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 COPPER AVE NE
ALBUQUERQUE NM
87108-1473
US

IV. Provider business mailing address

8809 COMANCHE RD NE
ALBUQUERQUE NM
87111-3363
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-5557
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3456
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: