Provider Demographics
NPI:1104111640
Name:MACHADO-GONZALEZ, YANIVIS (BCBA, LMHC)
Entity type:Individual
Prefix:
First Name:YANIVIS
Middle Name:
Last Name:MACHADO-GONZALEZ
Suffix:
Gender:F
Credentials:BCBA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9243 SW 172ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-2954
Mailing Address - Country:US
Mailing Address - Phone:305-903-3220
Mailing Address - Fax:866-517-3411
Practice Address - Street 1:12930 SW 128TH ST
Practice Address - Street 2:SUITE 204A1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6038
Practice Address - Country:US
Practice Address - Phone:305-562-4683
Practice Address - Fax:866-517-3411
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-10380103K00000X
FLMH 11537101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693402196Medicaid