Provider Demographics
NPI:1952134546
Name:BRACHO GONZALES, ALEXANDER JOSE
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JOSE
Last Name:BRACHO GONZALES
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 1:812 MONTGOMERY WAY
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-6315
Mailing Address - Country:US
Mailing Address - Phone:689-253-8870
Mailing Address - Fax:
Practice Address - Street 1:812 MONTGOMERY WAY
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-6315
Practice Address - Country:US
Practice Address - Phone:689-253-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty