Provider Demographics
NPI:1316171424
Name:GONZALES, MARY LAURA (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LAURA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W. SUNSET
Mailing Address - Street 2:B
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209
Mailing Address - Country:US
Mailing Address - Phone:210-402-4077
Mailing Address - Fax:210-402-2922
Practice Address - Street 1:202 W. SUNSET
Practice Address - Street 2:B
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209
Practice Address - Country:US
Practice Address - Phone:210-402-4077
Practice Address - Fax:210-402-2922
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103765235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist