Provider Demographics
NPI:1114694445
Name:GONZALEZ, JUAN ALBERTO
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ALBERTO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26005 SW 144TH AVE APT 122
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5649
Mailing Address - Country:US
Mailing Address - Phone:786-403-9232
Mailing Address - Fax:
Practice Address - Street 1:26005 SW 144TH AVE APT 122
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5649
Practice Address - Country:US
Practice Address - Phone:786-403-9232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-140601106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician