Provider Demographics
NPI:1619674348
Name:CLEMENTE-GONZALEZ, CARELISSE
Entity Type:Individual
Prefix:
First Name:CARELISSE
Middle Name:
Last Name:CLEMENTE-GONZALEZ
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 1:907 TIDEWATER LN APT 131
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-6540
Mailing Address - Country:US
Mailing Address - Phone:407-496-9112
Mailing Address - Fax:
Practice Address - Street 1:8001 BEATY GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1602
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician