Provider Demographics
NPI:1992305924
Name:GONZALEZ GUTIERREZ, IRIALIS
Entity type:Individual
Prefix:
First Name:IRIALIS
Middle Name:
Last Name:GONZALEZ GUTIERREZ
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 1:6261 W FLAGLER ST APT 22
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3024
Mailing Address - Country:US
Mailing Address - Phone:786-487-2788
Mailing Address - Fax:
Practice Address - Street 1:6261 W FLAGLER ST APT 22
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-3024
Practice Address - Country:US
Practice Address - Phone:786-487-2788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty