Provider Demographics
NPI:1336507425
Name:GONZALEZ, LISA (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MUNTIMURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:RI
Mailing Address - Zip Code:02822-2206
Mailing Address - Country:US
Mailing Address - Phone:401-932-9474
Mailing Address - Fax:
Practice Address - Street 1:28 MOCKINGBIRD DR
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:RI
Practice Address - Zip Code:02822-2206
Practice Address - Country:US
Practice Address - Phone:401-932-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI0-14-5968103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst