Provider Demographics
NPI:1275356412
Name:GONZALEZ, DAKOTA J (LMT)
Entity type:Individual
Prefix:MR
First Name:DAKOTA
Middle Name:J
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3428 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1618
Mailing Address - Country:US
Mailing Address - Phone:636-399-4591
Mailing Address - Fax:
Practice Address - Street 1:2716 SUTTON BLVD
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143-3036
Practice Address - Country:US
Practice Address - Phone:636-399-4591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018037470225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist