Provider Demographics
NPI:1336996495
Name:GONZALEZ MAYO, LISET (RBT)
Entity type:Individual
Prefix:
First Name:LISET
Middle Name:
Last Name:GONZALEZ MAYO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 SW 143RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6668
Mailing Address - Country:US
Mailing Address - Phone:305-582-4074
Mailing Address - Fax:
Practice Address - Street 1:11820 MIRAMAR PKWY STE 109
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-5815
Practice Address - Country:US
Practice Address - Phone:786-399-8439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-308414106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician