Healthcare Provider Details

I. General information

NPI: 1093162901
Provider Name (Legal Business Name): MR. CARLOS A GONZALEZ ORTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 E 37TH ST
HIALEAH FL
33013-2847
US

IV. Provider business mailing address

748 E 37TH ST
HIALEAH FL
33013-2847
US

V. Phone/Fax

Practice location:
  • Phone: 786-319-7603
  • Fax:
Mailing address:
  • Phone: 786-319-7603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-54657
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: