Provider Demographics
NPI:1164055448
Name:GONZALEZ, AILYN
Entity Type:Individual
Prefix:
First Name:AILYN
Middle Name:
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 1:4100 WINSTON COURT, APT 101
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5061
Mailing Address - Country:US
Mailing Address - Phone:305-332-5551
Mailing Address - Fax:
Practice Address - Street 1:3831 W VINE STREET
Practice Address - Street 2:60
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5061
Practice Address - Country:US
Practice Address - Phone:305-332-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
20113137106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104640500Medicaid
FL20113137OtherRBT CERTIFICATION NUMBER