Provider Demographics
NPI:1407422116
Name:GONZALEZ PAVON, MIGUEL MARIANO
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:MARIANO
Last Name:GONZALEZ PAVON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7255 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3805
Mailing Address - Country:US
Mailing Address - Phone:786-860-8357
Mailing Address - Fax:
Practice Address - Street 1:7255 W 15TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3805
Practice Address - Country:US
Practice Address - Phone:786-860-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-138953106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician