Provider Demographics
NPI:1992474423
Name:GONZALEZ QUINTANA, LISSETT (MA 93851)
Entity type:Individual
Prefix:
First Name:LISSETT
Middle Name:
Last Name:GONZALEZ QUINTANA
Suffix:
Gender:F
Credentials:MA 93851
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 W 25TH PL APT 3
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-1831
Mailing Address - Country:US
Mailing Address - Phone:786-379-3650
Mailing Address - Fax:
Practice Address - Street 1:8504 NW 103RD ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-4870
Practice Address - Country:US
Practice Address - Phone:786-420-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA93851225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist