Healthcare Provider Details

I. General information

NPI: 1366030322
Provider Name (Legal Business Name): EVELYN GONZALEZ BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 GRANADA DR
LAKE WORTH FL
33461-2005
US

IV. Provider business mailing address

117 GRANADA DR
LAKE WORTH FL
33461-2005
US

V. Phone/Fax

Practice location:
  • Phone: 561-574-7341
  • Fax:
Mailing address:
  • Phone: 561-574-7341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number20-137512
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: