Provider Demographics
NPI:1649982497
Name:GONZALEZ MARTINEZ, LADY MARIA
Entity type:Individual
Prefix:
First Name:LADY
Middle Name:MARIA
Last Name:GONZALEZ MARTINEZ
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 1:5260 NW 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-3344
Mailing Address - Country:US
Mailing Address - Phone:786-602-2886
Mailing Address - Fax:
Practice Address - Street 1:5260 NW 32ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-3344
Practice Address - Country:US
Practice Address - Phone:786-602-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-249774106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician