Provider Demographics
NPI:1831455583
Name:GONZALEZ-WIGGS, CLARISSA AURELIA (LMT)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:AURELIA
Last Name:GONZALEZ-WIGGS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 MEADOWDALE DR
Mailing Address - Street 2:
Mailing Address - City:ROYSE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75189-3513
Mailing Address - Country:US
Mailing Address - Phone:310-699-7876
Mailing Address - Fax:
Practice Address - Street 1:337 OAKS TRL STE 111
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-4096
Practice Address - Country:US
Practice Address - Phone:310-699-7876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT102538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT102538OtherMASSAGE THERAPIST