Provider Demographics
NPI:1023434370
Name:EFRAIN A. GONZALEZ PL
Entity type:Organization
Organization Name:EFRAIN A. GONZALEZ PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EFRAIN
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-218-5540
Mailing Address - Street 1:8589 SW 115TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-4202
Mailing Address - Country:US
Mailing Address - Phone:305-218-5540
Mailing Address - Fax:
Practice Address - Street 1:2730 SW 3RD AVE STE 202A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129-2323
Practice Address - Country:US
Practice Address - Phone:305-218-5540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3731103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767612300Medicaid
FL767612300Medicaid