Provider Demographics
NPI:1699312892
Name:GONZALEZ CASTRO, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:GONZALEZ CASTRO
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 1:5467 1ST AVE E APT 207
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-6149
Mailing Address - Country:US
Mailing Address - Phone:727-421-6834
Mailing Address - Fax:
Practice Address - Street 1:1902 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4602
Practice Address - Country:US
Practice Address - Phone:941-761-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15573235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist