Provider Demographics
NPI:1912372426
Name:GONZALEZ, LICELOT (RBT)
Entity Type:Individual
Prefix:
First Name:LICELOT
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MEADOWLANDS PKWY
Mailing Address - Street 2:SUITE 142
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-1633
Mailing Address - Country:US
Mailing Address - Phone:201-446-7580
Mailing Address - Fax:
Practice Address - Street 1:600 MEADOWLANDS PKWY
Practice Address - Street 2:SUITE 142
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-1633
Practice Address - Country:US
Practice Address - Phone:201-446-7580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2016-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist