Provider Demographics
NPI:1619741444
Name:DE LA OLIVA GONZALEZ, LAURA EULALIA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EULALIA
Last Name:DE LA OLIVA 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 1:600 NW 6TH ST APT 1412
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-3272
Mailing Address - Country:US
Mailing Address - Phone:305-632-0932
Mailing Address - Fax:
Practice Address - Street 1:600 NW 6TH ST APT 1412
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-3272
Practice Address - Country:US
Practice Address - Phone:305-632-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-304769106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician