Healthcare Provider Details

I. General information

NPI: 1295575447
Provider Name (Legal Business Name): JESUS CAMILO GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4793 N CONGRESS AVE STE 203
BOYNTON BEACH FL
33426-7937
US

IV. Provider business mailing address

76 LAKE ARBOR DR
PALM SPRINGS FL
33461-2150
US

V. Phone/Fax

Practice location:
  • Phone: 561-429-3863
  • Fax:
Mailing address:
  • Phone: 561-685-7232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-324607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: