Provider Demographics
NPI:1992340426
Name:GONZALEZ, ANGELICA RIVERA (MT)
Entity type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:RIVERA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 BERGENWOOD AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5347
Mailing Address - Country:US
Mailing Address - Phone:551-224-1950
Mailing Address - Fax:
Practice Address - Street 1:8915 BERGENWOOD AVE APT 5
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5347
Practice Address - Country:US
Practice Address - Phone:551-224-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01031000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist