Provider Demographics
NPI:1952815912
Name:GONZALEZ, KAELEIGH
Entity Type:Individual
Prefix:
First Name:KAELEIGH
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 1:32575 OKALOOSA TRL
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:FL
Mailing Address - Zip Code:32776-8990
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3625
Practice Address - Country:US
Practice Address - Phone:407-915-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst