Provider Demographics
NPI:1245829464
Name:GONZALEZ JUSTIZ, DAILINE
Entity type:Individual
Prefix:
First Name:DAILINE
Middle Name:
Last Name:GONZALEZ JUSTIZ
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 1:4309 SW 129TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4019
Mailing Address - Country:US
Mailing Address - Phone:786-804-9880
Mailing Address - Fax:
Practice Address - Street 1:4309 SW 129TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-4019
Practice Address - Country:US
Practice Address - Phone:786-804-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20149959106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician