Provider Demographics
NPI:1083420301
Name:CONCEPCION GONZALEZ, RANDY (MS)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:CONCEPCION GONZALEZ
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12665 NE 16TH AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5289
Mailing Address - Country:US
Mailing Address - Phone:786-614-3425
Mailing Address - Fax:
Practice Address - Street 1:12665 NE 16TH AVE APT 7
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5289
Practice Address - Country:US
Practice Address - Phone:786-614-3425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-387241106S00000X
171400000X, 246ZE0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171400000XOther Service ProvidersHealth & Wellness Coach