Provider Demographics
NPI:1245757277
Name:GONZALEZ, DIEGO MANUEL
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:MANUEL
Last Name:GONZALEZ
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 1:472 NW 98TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4037
Mailing Address - Country:US
Mailing Address - Phone:786-718-2170
Mailing Address - Fax:
Practice Address - Street 1:2500 SW 107TH AVE STE 42
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2492
Practice Address - Country:US
Practice Address - Phone:786-615-3334
Practice Address - Fax:786-615-3257
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21881101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health