Provider Demographics
NPI:1609633841
Name:GONZALEZ MEDINA, MARIELYS
Entity Type:Individual
Prefix:
First Name:MARIELYS
Middle Name:
Last Name:GONZALEZ MEDINA
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 1:27570 S DIXIE HWY UNIT 409
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8491
Mailing Address - Country:US
Mailing Address - Phone:786-388-7852
Mailing Address - Fax:
Practice Address - Street 1:27570 S DIXIE HWY UNIT 409
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-8491
Practice Address - Country:US
Practice Address - Phone:786-388-7852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-330632106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty