Healthcare Provider Details

I. General information

NPI: 1174324859
Provider Name (Legal Business Name): MIGUEL GONZALEZ FERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9777 STELLA PALM WAY UNIT 420
FORT MYERS FL
33966-6600
US

IV. Provider business mailing address

9777 STELLA PALM WAY UNIT 420
FORT MYERS FL
33966-6600
US

V. Phone/Fax

Practice location:
  • Phone: 786-445-8247
  • Fax:
Mailing address:
  • Phone: 786-445-8247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number25420283
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: