Provider Demographics
NPI:1063183374
Name:GONZALEZ, MIA L (OTD)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:L
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 1/2 E HIGH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43526-1181
Mailing Address - Country:US
Mailing Address - Phone:201-248-1578
Mailing Address - Fax:
Practice Address - Street 1:1751 WESLEY RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-3647
Practice Address - Country:US
Practice Address - Phone:260-925-5494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-26
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007525A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist