Provider Demographics
NPI:1699280461
Name:GONZALEZ, BIANCA M
Entity type:Individual
Prefix:MISS
First Name:BIANCA
Middle Name:M
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 1:5979 NW 151ST ST STE 102I
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2434
Mailing Address - Country:US
Mailing Address - Phone:786-953-5120
Mailing Address - Fax:786-636-6965
Practice Address - Street 1:5979 NW 151ST ST STE 102I
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2434
Practice Address - Country:US
Practice Address - Phone:786-953-5120
Practice Address - Fax:786-636-6965
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-02
Last Update Date:2018-11-16
Deactivation Date:2018-04-27
Deactivation Code:
Reactivation Date:2018-08-29
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLCNA334670376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty