Provider Demographics
NPI:1629592019
Name:CALDERON GONZALEZ, ERNESTO ANTONIO
Entity Type:Individual
Prefix:MR
First Name:ERNESTO
Middle Name:ANTONIO
Last Name:CALDERON 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 1:1150 COLLINS AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-4646
Mailing Address - Country:US
Mailing Address - Phone:786-307-9664
Mailing Address - Fax:
Practice Address - Street 1:1150 COLLINS AVE APT 306
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-4646
Practice Address - Country:US
Practice Address - Phone:786-307-9664
Practice Address - Fax:786-307-9664
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician