Provider Demographics
NPI:1376206359
Name:GOLD COAST EVOLUTION CENTER INC
Entity Type:Organization
Organization Name:GOLD COAST EVOLUTION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LINA
Authorized Official - Last Name:LEZCANO DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-496-9661
Mailing Address - Street 1:3801 PGA BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2756
Mailing Address - Country:US
Mailing Address - Phone:305-496-9661
Mailing Address - Fax:
Practice Address - Street 1:3801 PGA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2756
Practice Address - Country:US
Practice Address - Phone:305-496-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty