Provider Demographics
NPI:1548766462
Name:GONZALEZ, IDANIA MERCEDES
Entity Type:Individual
Prefix:
First Name:IDANIA
Middle Name:MERCEDES
Last Name:GONZALEZ
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 1:9300 W FLAGLER ST APT 207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-3404
Mailing Address - Country:US
Mailing Address - Phone:941-787-9013
Mailing Address - Fax:
Practice Address - Street 1:9300 W FLAGLER ST APT 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-3404
Practice Address - Country:US
Practice Address - Phone:941-787-9013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician