Provider Demographics
NPI:1184383325
Name:GONZALEZ, LISSETT
Entity type:Individual
Prefix:
First Name:LISSETT
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 1:6200 W FLAGLER ST APT 401
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3082
Mailing Address - Country:US
Mailing Address - Phone:786-508-3897
Mailing Address - Fax:
Practice Address - Street 1:6200 W FLAGLER ST APT 401
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-3082
Practice Address - Country:US
Practice Address - Phone:786-508-3897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-119051106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst