Provider Demographics
NPI:1134875867
Name:GONZALEZ GARCIA, RAFAEL
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:GONZALEZ GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5077 NW 7TH ST APT 1606
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3467
Mailing Address - Country:US
Mailing Address - Phone:786-302-8441
Mailing Address - Fax:
Practice Address - Street 1:5077 NW 7TH ST APT 1606
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-3467
Practice Address - Country:US
Practice Address - Phone:786-302-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112914100Medicaid