Provider Demographics
NPI:1265180863
Name:MESA GONZALEZ, MARIA FERNANDA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:FERNANDA
Last Name:MESA 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 1:17811 NW 66TH COURT CIR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4423
Mailing Address - Country:US
Mailing Address - Phone:305-469-5613
Mailing Address - Fax:
Practice Address - Street 1:17811 NW 66TH COURT CIR
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4423
Practice Address - Country:US
Practice Address - Phone:305-469-5613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-197267106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician