Provider Demographics
NPI:1164258927
Name:GONSALVES, GINA MARIE
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 W 22ND ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-5953
Mailing Address - Country:US
Mailing Address - Phone:310-991-1402
Mailing Address - Fax:
Practice Address - Street 1:17150 VIA DEL CAMPO STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-2137
Practice Address - Country:US
Practice Address - Phone:858-381-5084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist