Provider Demographics
NPI:1578078051
Name:GONZALEZ, LAZARA JULIET (RBT)
Entity Type:Individual
Prefix:
First Name:LAZARA
Middle Name:JULIET
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 1:2301 MAITLAND CENTER PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7415
Mailing Address - Country:US
Mailing Address - Phone:407-574-4629
Mailing Address - Fax:407-574-3091
Practice Address - Street 1:1820 ARMSTRONG BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2589
Practice Address - Country:US
Practice Address - Phone:407-852-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019556300Medicaid