Provider Demographics
NPI:1386471381
Name:GONZALES, ETHAN CARLOS (DPT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:CARLOS
Last Name:GONZALES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 GOOD INTENT RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-4458
Mailing Address - Country:US
Mailing Address - Phone:856-834-4839
Mailing Address - Fax:
Practice Address - Street 1:999 ROUTE 73 N FL 4
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1227
Practice Address - Country:US
Practice Address - Phone:856-821-6372
Practice Address - Fax:856-821-6339
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02289100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist