Provider Demographics
NPI:1730628132
Name:GONZALEZ, LOURDES M
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:M
Last Name: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 1:7855 NW 12TH ST
Mailing Address - Street 2:SUITE 117
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126
Mailing Address - Country:US
Mailing Address - Phone:786-617-2128
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:7855 NW 12TH ST
Practice Address - Street 2:SUITE 117
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126
Practice Address - Country:US
Practice Address - Phone:786-617-2128
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician