Provider Demographics
NPI:1932650785
Name:GONZALEZ, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
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 1:201 HUNT ST
Mailing Address - Street 2:APT 1622
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2484
Mailing Address - Country:US
Mailing Address - Phone:787-633-7208
Mailing Address - Fax:
Practice Address - Street 1:201 HUNT ST
Practice Address - Street 2:APT 1622
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2484
Practice Address - Country:US
Practice Address - Phone:787-633-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
FLG524300767460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015614700Medicaid