Healthcare Provider Details

I. General information

NPI: 1295201846
Provider Name (Legal Business Name): GRISSEL ALFONSO GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 SE 34TH ST
CAPE CORAL FL
33904-4291
US

IV. Provider business mailing address

1219 SE 34TH ST
CAPE CORAL FL
33904-4291
US

V. Phone/Fax

Practice location:
  • Phone: 239-703-3502
  • Fax: 844-640-0724
Mailing address:
  • Phone: 239-703-3502
  • Fax: 844-640-0724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: