Provider Demographics
NPI:1174324859
Name:GONZALEZ FERNANDEZ, MIGUEL
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:GONZALEZ FERNANDEZ
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 1:23187 SW 108TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-7536
Mailing Address - Country:US
Mailing Address - Phone:786-445-8247
Mailing Address - Fax:
Practice Address - Street 1:480 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-4542
Practice Address - Country:US
Practice Address - Phone:786-343-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25420283103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst