Provider Demographics
NPI:1558833822
Name:GONZALEZ LOPEZ, OSVALDO (BCABA)
Entity Type:Individual
Prefix:
First Name:OSVALDO
Middle Name:
Last Name:GONZALEZ LOPEZ
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8974 NW 112TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4517
Mailing Address - Country:US
Mailing Address - Phone:305-987-1377
Mailing Address - Fax:
Practice Address - Street 1:15819 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1593
Practice Address - Country:US
Practice Address - Phone:305-987-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-9923106E00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023554800Medicaid