Provider Demographics
NPI:1841648979
Name:GONZALEZ LASTRE, YAMILET
Entity type:Individual
Prefix:
First Name:YAMILET
Middle Name:
Last Name:GONZALEZ LASTRE
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 1:7400 SW 139TH TER
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33158-1228
Mailing Address - Country:US
Mailing Address - Phone:786-294-3483
Mailing Address - Fax:
Practice Address - Street 1:7400 SW 139TH TER
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33158-1228
Practice Address - Country:US
Practice Address - Phone:786-294-3483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-19-35888103K00000X
FL0-17-8220106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018068900Medicaid
FL0-17-8220OtherBEHAVIOR ANALYST CERTIFICATION BOARD