Provider Demographics
NPI:1104462647
Name:GONZALEZ, JOSE RAPHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RAPHAEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SW 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3510
Mailing Address - Country:US
Mailing Address - Phone:305-218-2425
Mailing Address - Fax:
Practice Address - Street 1:1848 SE 1ST AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2875
Practice Address - Country:US
Practice Address - Phone:954-885-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13471101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health