Provider Demographics
NPI:1659981744
Name:GONZALEZ DOMINGUEZ, LIDIA D
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:D
Last Name:GONZALEZ DOMINGUEZ
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 1:12502 SW 223RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-4497
Mailing Address - Country:US
Mailing Address - Phone:786-562-4746
Mailing Address - Fax:
Practice Address - Street 1:12502 SW 223RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-4497
Practice Address - Country:US
Practice Address - Phone:786-562-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician