Provider Demographics
NPI:1881209716
Name:GONZALEZ HERNANDEZ, MARICELA I
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:GONZALEZ HERNANDEZ
Suffix:I
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 1:6191 W 24TH AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6903
Mailing Address - Country:US
Mailing Address - Phone:786-908-4278
Mailing Address - Fax:
Practice Address - Street 1:6191 W 24TH AVE APT 104
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-6903
Practice Address - Country:US
Practice Address - Phone:786-908-4278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-127370103K00000X
20-127370106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst