Provider Demographics
NPI:1679372940
Name:GONZALEZ, CARMEN D
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:D
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19958 SW 123RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-4945
Mailing Address - Country:US
Mailing Address - Phone:786-230-4238
Mailing Address - Fax:
Practice Address - Street 1:19958 SW 123RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-4945
Practice Address - Country:US
Practice Address - Phone:786-230-4238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-388159106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician