Provider Demographics
NPI:1407555394
Name:GONZALEZ, LIDA ROSA (RBT)
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:ROSA
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 1:2461 W 76TH ST APT 210
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5674
Mailing Address - Country:US
Mailing Address - Phone:305-333-8562
Mailing Address - Fax:
Practice Address - Street 1:2461 W 76TH ST APT 210
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5674
Practice Address - Country:US
Practice Address - Phone:305-333-8562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-125115106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician