Provider Demographics
NPI:1093203085
Name:GONZALEZ LOPEZ, YENIS
Entity Type:Individual
Prefix:
First Name:YENIS
Middle Name:
Last Name:GONZALEZ LOPEZ
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 1:12772 NW 102ND PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-6028
Mailing Address - Country:US
Mailing Address - Phone:786-398-2965
Mailing Address - Fax:
Practice Address - Street 1:12772 NW 102ND PL
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-6028
Practice Address - Country:US
Practice Address - Phone:786-398-2965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X, 106S00000X
FL1-21-53808103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician