Provider Demographics
NPI:1275296725
Name:GONZALEZ, THALIA DANIELA (RBT)
Entity Type:Individual
Prefix:
First Name:THALIA
Middle Name:DANIELA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 W FLAGLER ST APT 103
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3248
Mailing Address - Country:US
Mailing Address - Phone:786-413-5478
Mailing Address - Fax:
Practice Address - Street 1:2032 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-4515
Practice Address - Country:US
Practice Address - Phone:786-413-5478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-152537106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician