Provider Demographics
NPI:1679138390
Name:GONZALEZ LEON, KARIN
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:
Last Name:GONZALEZ LEON
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 1:615 NE 22ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-5107
Mailing Address - Country:US
Mailing Address - Phone:954-997-3629
Mailing Address - Fax:
Practice Address - Street 1:12700 SW 122ND AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5271
Practice Address - Country:US
Practice Address - Phone:786-353-2900
Practice Address - Fax:786-364-1676
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-84458106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician