Provider Demographics
NPI:1942600218
Name:GONZALES, FIDES FAITH (OTR/L, MA)
Entity type:Individual
Prefix:
First Name:FIDES FAITH
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:OTR/L, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S FREMONT AVE UNIT 27
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-8849
Mailing Address - Country:US
Mailing Address - Phone:213-607-4400
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE UNIT 27
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8849
Practice Address - Country:US
Practice Address - Phone:213-607-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-24
Last Update Date:2014-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14343225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist