Provider Demographics
NPI:1770737603
Name:GONZALEZ, JORGE L
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:L
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 1:8425 NW 8TH ST
Mailing Address - Street 2:403
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3769
Mailing Address - Country:US
Mailing Address - Phone:305-389-0709
Mailing Address - Fax:305-261-1890
Practice Address - Street 1:8425 NW 8TH ST
Practice Address - Street 2:403
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-3769
Practice Address - Country:US
Practice Address - Phone:305-389-0709
Practice Address - Fax:305-261-1890
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-03-0981103K00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676238798Medicaid
FL691481179Medicaid
FL676238796Medicaid
FL676238700Medicaid