Healthcare Provider Details

I. General information

NPI: 1215544762
Provider Name (Legal Business Name): STEVEN EMMANUELLE GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 W INTERSTATE 2 STE 3
PHARR TX
78577-6563
US

IV. Provider business mailing address

305 NE LOOP 820; BUSINESS TOWER 1 SUITE 200
HURST TX
76053
US

V. Phone/Fax

Practice location:
  • Phone: 956-510-8777
  • Fax:
Mailing address:
  • Phone: 817-292-8787
  • Fax: 817-789-6849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2155784
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: