Provider Demographics
NPI:1982478723
Name:GONZALEZ MARTINEZ, MILENA
Entity type:Individual
Prefix:
First Name:MILENA
Middle Name:
Last Name:GONZALEZ MARTINEZ
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 1:3107 NW EMBERS TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-6907
Mailing Address - Country:US
Mailing Address - Phone:903-337-7947
Mailing Address - Fax:
Practice Address - Street 1:3107 NW EMBERS TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-6907
Practice Address - Country:US
Practice Address - Phone:903-337-7947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-294750106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty