Provider Demographics
NPI:1043754559
Name:GONZALEZ, GLENDA ORIA (BCABA)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:ORIA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 E 31ST ST APT 1
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3365
Mailing Address - Country:US
Mailing Address - Phone:786-366-9526
Mailing Address - Fax:
Practice Address - Street 1:6501 SW 139TH CT APT 305
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-2088
Practice Address - Country:US
Practice Address - Phone:786-366-9526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-20-41368103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019525300Medicaid
BCABA-0-18-8814OtherBEHAVIOR ANALYST CERTIFICATION BOARD