MEDICARE: MRS. REBECCA RAE GONZALEZ M.S. CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	5289	OK

General Provider Information

NPI Number	:	1164042164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA RAE GONZALEZ M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	2929 COLONIAL LN
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73013-6477
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9070 HARMONY DR STE A
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6257
Country	:	US
Telephone Number	:	405-455-5582
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2020
Last Update Date	:	04/20/2020

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Directions to “ MRS. REBECCA RAE GONZALEZ M.S. CCC-SLP” Practice Location

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