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General NPI Number Information
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NPI Number | 1164258927
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Entity Type | Individual
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Provider Name | GINA MARIE GONSALVES
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Gender | Female
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Dates
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Enumeration Date | 09/10/2024
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Last Update Date | 09/29/2024
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Provider Practice Location Address
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Address Line | 17150 VIA DEL CAMPO STE 200
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City | SAN DIEGO
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State | CA
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Zip | 92127-2137
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Country | US
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Telephone | 858-381-5084
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Fax |
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Provider Business Mailing Address
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Address Line | 623 W 22ND ST APT 4
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City | SAN PEDRO
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State | CA
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Zip | 90731-5953
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Country | US
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Telephone | 310-991-1402
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 306782
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License Number State | CA
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