Provider Demographics
NPI:1104536101
Name:GONZALEZ, ISABELLA MARIA
Entity type:Individual
Prefix:
First Name:ISABELLA
Middle Name:MARIA
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 1:9415 SW 72ND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-5493
Mailing Address - Country:US
Mailing Address - Phone:305-662-6448
Mailing Address - Fax:
Practice Address - Street 1:9415 SW 72ND ST STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-5493
Practice Address - Country:US
Practice Address - Phone:305-662-6448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty