Provider Demographics
NPI:1902147283
Name:GONZALES, TAMMY (CNMT)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 W GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1442
Mailing Address - Country:US
Mailing Address - Phone:719-821-1180
Mailing Address - Fax:
Practice Address - Street 1:613 W GRANT AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1442
Practice Address - Country:US
Practice Address - Phone:719-821-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0004628171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor