Healthcare Provider Details

I. General information

NPI: 1255055067
Provider Name (Legal Business Name): JEFFREY GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PARK PLACE BLVD
KISSIMMEE FL
34741-2345
US

IV. Provider business mailing address

2051 THE OAKS BLVD
KISSIMMEE FL
34746-4509
US

V. Phone/Fax

Practice location:
  • Phone: 407-785-1009
  • Fax:
Mailing address:
  • Phone: 407-575-2164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: