Provider Demographics
NPI:1801376223
Name:GONZALEZ, RAQUEL
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name: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 1:1900 W 68TH ST APT D308
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4476
Mailing Address - Country:US
Mailing Address - Phone:786-333-1477
Mailing Address - Fax:
Practice Address - Street 1:1900 W 68TH ST APT D308
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4476
Practice Address - Country:US
Practice Address - Phone:786-333-1477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018865800Medicaid
FL018163000Medicaid