Provider Demographics
NPI:1245995117
Name:GONZALEZ, JESUS (BCABA)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8785 SW 165TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-5827
Mailing Address - Country:US
Mailing Address - Phone:786-655-9306
Mailing Address - Fax:
Practice Address - Street 1:850 NW FEDERAL HWY STE 173
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1019
Practice Address - Country:US
Practice Address - Phone:772-363-9878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
G524-433-00-363-0106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst