Provider Demographics
NPI:1285294074
Name:GONZALEZ, MATHEW LEE
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:LEE
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14336 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6146
Mailing Address - Country:US
Mailing Address - Phone:786-239-4471
Mailing Address - Fax:
Practice Address - Street 1:14336 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-6146
Practice Address - Country:US
Practice Address - Phone:786-239-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician