Provider Demographics
NPI:1871199885
Name:GONZALEZ, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name: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 1:103530 OVERSEAS HWY
Mailing Address - Street 2:
Mailing Address - City:KEY LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33037-2839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103530 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:KEY LARGO
Practice Address - State:FL
Practice Address - Zip Code:33037-2839
Practice Address - Country:US
Practice Address - Phone:305-984-8908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-139495106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician