Provider Demographics
NPI:1215304357
Name:GONZALEZ, STEPHANIE (LMT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 DECLARATION LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-7344
Mailing Address - Country:US
Mailing Address - Phone:630-806-5471
Mailing Address - Fax:
Practice Address - Street 1:2712 FORGUE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4194
Practice Address - Country:US
Practice Address - Phone:630-922-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227013325225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist