Provider Demographics
NPI:1275008864
Name:GONZALEZ, ELAYNE GABRIELA
Entity Type:Individual
Prefix:
First Name:ELAYNE
Middle Name:GABRIELA
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 1:9711 NW 126TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-7408
Mailing Address - Country:US
Mailing Address - Phone:786-342-5962
Mailing Address - Fax:
Practice Address - Street 1:9711 NW 126TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-7408
Practice Address - Country:US
Practice Address - Phone:786-479-5548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCMS.0101122171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCBHCM.0103066OtherFLORIDA CERTIFICATION BOARD