Provider Demographics
NPI:1942041074
Name:GONZALEZ, MAILENIZ
Entity type:Individual
Prefix:
First Name:MAILENIZ
Middle Name:
Last Name:GONZALEZ
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 1:1404 VILLAGE BLVD APT 1336
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-2719
Mailing Address - Country:US
Mailing Address - Phone:305-877-0501
Mailing Address - Fax:
Practice Address - Street 1:1401 VILLAGE BLVD APT 1336
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-2700
Practice Address - Country:US
Practice Address - Phone:305-877-0501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-24-345696106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician