Provider Demographics
NPI:1467295931
Name:GONZALEZ, JONATHAN GUSTAVO
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GUSTAVO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 SW 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3453
Mailing Address - Country:US
Mailing Address - Phone:786-355-0297
Mailing Address - Fax:
Practice Address - Street 1:3422 SW 112TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3453
Practice Address - Country:US
Practice Address - Phone:786-355-0297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician