Provider Demographics
NPI:1265288948
Name:MORAN GONZALEZ, MELISSA MAURA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MAURA
Last Name:MORAN 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 1:1716 PIERCE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6042
Mailing Address - Country:US
Mailing Address - Phone:561-313-9019
Mailing Address - Fax:
Practice Address - Street 1:1716 PIERCE DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH BEACH
Practice Address - State:FL
Practice Address - Zip Code:33460-6042
Practice Address - Country:US
Practice Address - Phone:561-313-9019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-341266106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician