Provider Demographics
NPI:1932858321
Name:GONZALEZ PAK, MILEIDYS
Entity Type:Individual
Prefix:
First Name:MILEIDYS
Middle Name:
Last Name:GONZALEZ PAK
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 1:2417 SW 17TH AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3856
Mailing Address - Country:US
Mailing Address - Phone:786-623-8862
Mailing Address - Fax:
Practice Address - Street 1:2417 SW 17TH AVE APT 15
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-3856
Practice Address - Country:US
Practice Address - Phone:786-623-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-141117106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111996400Medicaid