Provider Demographics
NPI:1043009467
Name:GONZALEZ MURSULY, JAN LUCAS
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:LUCAS
Last Name:GONZALEZ MURSULY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 S FL MANGO RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-3117
Mailing Address - Country:US
Mailing Address - Phone:561-306-3152
Mailing Address - Fax:
Practice Address - Street 1:303 S FL MANGO RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-3117
Practice Address - Country:US
Practice Address - Phone:561-306-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician