Provider Demographics
NPI:1174175533
Name:GONZALEZ BORGES, LUIS JOSE
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:JOSE
Last Name:GONZALEZ BORGES
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 1:440 W 42ND PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3850
Mailing Address - Country:US
Mailing Address - Phone:305-930-3531
Mailing Address - Fax:
Practice Address - Street 1:440 W 42ND PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3850
Practice Address - Country:US
Practice Address - Phone:305-930-3531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-75662106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician