Provider Demographics
NPI:1861881583
Name:GONZALEZ, DAVID M (MS, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MS, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 VILLAGE DR APT B
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-8229
Mailing Address - Country:US
Mailing Address - Phone:516-369-6691
Mailing Address - Fax:
Practice Address - Street 1:991 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1608
Practice Address - Country:US
Practice Address - Phone:516-369-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024078-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04092444Medicaid
14056528OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION CLINICAL COMPETENCE CERT.
NY024078-1OtherNEW YORK STATE EDUCATION DEPARTMENT OFFICE OF PROFESSIONS