Provider Demographics
NPI:1053031138
Name:GONZALEZ LEYVA, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:GONZALEZ LEYVA
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 1:338 PENDLETON AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-0410
Mailing Address - Country:US
Mailing Address - Phone:786-523-1804
Mailing Address - Fax:
Practice Address - Street 1:338 PENDLETON AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33974-0410
Practice Address - Country:US
Practice Address - Phone:786-523-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-228655106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty