Provider Demographics
NPI:1104334812
Name:GONZALEZ, DORISLEYDI
Entity type:Individual
Prefix:
First Name:DORISLEYDI
Middle Name:
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 1:7050 W FLAGLER ST APT 20
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2747
Mailing Address - Country:US
Mailing Address - Phone:305-490-7232
Mailing Address - Fax:
Practice Address - Street 1:7050 W FLAGLER ST APT 20
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2747
Practice Address - Country:US
Practice Address - Phone:305-490-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5011914106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL50-11914Medicaid