Provider Demographics
NPI:1053034116
Name:SUEQUE GONZALEZ, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SUEQUE GONZALEZ
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 1:150 ALTON RD APT 610
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-6726
Mailing Address - Country:US
Mailing Address - Phone:786-389-9402
Mailing Address - Fax:
Practice Address - Street 1:2609 43RD ST SW
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33976-4704
Practice Address - Country:US
Practice Address - Phone:786-389-9402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT22227391106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician