Provider Demographics
NPI:1699329466
Name:GONZALEZ CICILIO, CARLOS A
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:GONZALEZ CICILIO
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 1:13910 SW 268TH ST APT 107
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-9205
Mailing Address - Country:US
Mailing Address - Phone:786-259-4347
Mailing Address - Fax:
Practice Address - Street 1:13910 SW 268TH ST APT 107
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-9205
Practice Address - Country:US
Practice Address - Phone:786-259-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-64037106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician