Provider Demographics
NPI:1285334540
Name:GONZALEZ, MARIANGELA
Entity type:Individual
Prefix:
First Name:MARIANGELA
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 1:3341 NW 208TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-1364
Mailing Address - Country:US
Mailing Address - Phone:786-267-5570
Mailing Address - Fax:
Practice Address - Street 1:560 VILLAGE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-1963
Practice Address - Country:US
Practice Address - Phone:877-535-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-25574106S00000X
FLRBT-23-255674106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician