Provider Demographics
NPI:1699032532
Name:GONZALEZ, GLORIAM (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:GLORIAM
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 LAKEPOINTE DR UNIT 201
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5899
Mailing Address - Country:US
Mailing Address - Phone:786-879-6457
Mailing Address - Fax:
Practice Address - Street 1:380 LAKEPOINTE DR UNIT 201
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5899
Practice Address - Country:US
Practice Address - Phone:786-879-6457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-17
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12422225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005629600Medicaid