Provider Demographics
NPI:1033828470
Name:GONZALEZ, KRYSTAL HERBELIZ
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:HERBELIZ
Last Name:GONZALEZ
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 1:897 TOWNE CENTER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-3473
Mailing Address - Country:US
Mailing Address - Phone:407-201-4936
Mailing Address - Fax:502-223-4916
Practice Address - Street 1:120 WASHINGTON PALM LOOP
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-1637
Practice Address - Country:US
Practice Address - Phone:352-300-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician