Provider Demographics
NPI:1811710353
Name:GONZALEZ GONZALEZ, IAN ENRIQUE
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:ENRIQUE
Last Name:GONZALEZ GONZALEZ
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 1:777 NW 72ND AVE STE 1083
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3176
Mailing Address - Country:US
Mailing Address - Phone:786-490-6307
Mailing Address - Fax:
Practice Address - Street 1:5077 NW 7TH ST APT 1111
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-3464
Practice Address - Country:US
Practice Address - Phone:786-672-3609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician