Provider Demographics
NPI:1205344983
Name:GONZALEZ, MADILYN
Entity type:Individual
Prefix:
First Name:MADILYN
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 1:7991 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6877
Mailing Address - Country:US
Mailing Address - Phone:305-548-9051
Mailing Address - Fax:
Practice Address - Street 1:10650 W STATE ROAD 84 STE 206
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324
Practice Address - Country:US
Practice Address - Phone:954-634-3636
Practice Address - Fax:954-634-3637
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
FLRBT-18-61225106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023419800Medicaid