Provider Demographics
NPI:1730956905
Name:ESTRADA, GONZALO BENAVIDES JR (PT)
Entity type:Individual
Prefix:MR
First Name:GONZALO
Middle Name:BENAVIDES
Last Name:ESTRADA
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JUN
Other - Middle Name:B
Other - Last Name:ESTRADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:HAZEL HAWKINS REHAB. SERVICES
Mailing Address - Street 2:961A SUNSET DRIVE
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023
Mailing Address - Country:US
Mailing Address - Phone:831-635-1157
Mailing Address - Fax:831-636-9547
Practice Address - Street 1:HAZEL HAWKINS REHAB. SERVICES
Practice Address - Street 2:961A SUNSET DRIVE
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023
Practice Address - Country:US
Practice Address - Phone:831-635-1135
Practice Address - Fax:831-636-9547
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist