Provider Demographics
NPI:1437741857
Name:GONZALEZ DUQUE, SUSET THALIA
Entity Type:Individual
Prefix:
First Name:SUSET
Middle Name:THALIA
Last Name:GONZALEZ DUQUE
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 1:1040 ORIENTAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-2538
Mailing Address - Country:US
Mailing Address - Phone:786-597-8543
Mailing Address - Fax:
Practice Address - Street 1:1040 ORIENTAL BLVD
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-2538
Practice Address - Country:US
Practice Address - Phone:786-597-8543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-135856106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109404900Medicaid