Provider Demographics
NPI:1609538875
Name:GONZALEZ, JUAN R
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:R
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:08518-1318
Mailing Address - Country:US
Mailing Address - Phone:609-315-5992
Mailing Address - Fax:855-217-6179
Practice Address - Street 1:15 W FRONT ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:NJ
Practice Address - Zip Code:08518-1318
Practice Address - Country:US
Practice Address - Phone:609-315-5992
Practice Address - Fax:855-217-6179
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-19-93156106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician