Basic Information
| Provider Information | |||||||||
| NPI: | 1053768804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | CLEO | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MASSAGE THERAPIST | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 85 NE LOOP 410 | ||||||||
| Address2: | STE 214 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782165829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103754408 | ||||||||
| FaxNumber: | 8663815557 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 NE LOOP 410 | ||||||||
| Address2: | STE 214 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782165829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103754408 | ||||||||
| FaxNumber: | 8663815557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2016 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MT124958 | TX | Y | Other Service Providers | Specialist |
No ID Information.