Provider Demographics
NPI:1891915674
Name:GONZALEZ, YESSENIA DE LA LUZ
Entity Type:Individual
Prefix:MRS
First Name:YESSENIA
Middle Name:DE LA LUZ
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 1:1706 TURTLE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4267
Mailing Address - Country:US
Mailing Address - Phone:863-531-1552
Mailing Address - Fax:
Practice Address - Street 1:1706 TURTLE ROCK DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4267
Practice Address - Country:US
Practice Address - Phone:863-531-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILYG87630103P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist