Provider Demographics
NPI:1720289663
Name:GONZALEZ, GIRLIE M (LPT)
Entity type:Individual
Prefix:
First Name:GIRLIE
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:GIRLIE
Other - Middle Name:REYES
Other - Last Name:MALABANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:164 WADING RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-1107
Mailing Address - Country:US
Mailing Address - Phone:631-579-4424
Mailing Address - Fax:
Practice Address - Street 1:485 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1762
Practice Address - Country:US
Practice Address - Phone:631-475-0353
Practice Address - Fax:631-475-0399
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024955-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist