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General NPI Number Information
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NPI Number | 1205558467
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Entity Type | Individual
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Provider Name | LEONARDO GONZALEZ BAHAMONDE
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Gender | Male
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Dates
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Enumeration Date | 09/14/2022
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Last Update Date | 09/14/2022
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Provider Practice Location Address
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Address Line | 2808 LITHIA PINECREST RD
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City | VALRICO
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State | FL
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Zip | 33596-5615
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Country | US
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Telephone | 813-573-2905
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Fax |
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Provider Business Mailing Address
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Address Line | 902 ESSEX RD
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City | BRANDON
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State | FL
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Zip | 33510-2735
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Country | US
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Telephone |
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA32051
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License Number State | FL
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