Provider Demographics
NPI:1245577766
Name:GONZALEZ, GINA JANNAY (MA)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:JANNAY
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15311 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6005
Mailing Address - Country:US
Mailing Address - Phone:352-540-9335
Mailing Address - Fax:352-544-0722
Practice Address - Street 1:15311 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6005
Practice Address - Country:US
Practice Address - Phone:352-540-9335
Practice Address - Fax:352-544-0722
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH12699171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012660200Medicaid