Provider Demographics
NPI:1972179877
Name:REYES GONZALEZ, ILEANA MARIA
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:MARIA
Last Name:REYES 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 1:7645 W 34TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5015
Mailing Address - Country:US
Mailing Address - Phone:786-230-5567
Mailing Address - Fax:
Practice Address - Street 1:7645 W 34TH LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-5015
Practice Address - Country:US
Practice Address - Phone:786-230-5567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-163401106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician