Provider Demographics
NPI:1154824746
Name:GONZALEZ ROMAN, WILDALIZ (RBT)
Entity Type:Individual
Prefix:
First Name:WILDALIZ
Middle Name:
Last Name:GONZALEZ ROMAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:WILDALIZ
Other - Middle Name:
Other - Last Name:GONZALEZ ROMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:324 MIRASOL LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6725
Mailing Address - Country:US
Mailing Address - Phone:863-399-5513
Mailing Address - Fax:
Practice Address - Street 1:1334 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-2916
Practice Address - Country:US
Practice Address - Phone:407-601-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty