Provider Demographics
NPI:1578076238
Name:GONZALEZ, SANDRA (RBT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
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 1:6324 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5924
Mailing Address - Country:US
Mailing Address - Phone:754-465-4715
Mailing Address - Fax:
Practice Address - Street 1:6324 GRANT ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-5924
Practice Address - Country:US
Practice Address - Phone:754-465-4715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid