Healthcare Provider Details

I. General information

NPI: 1861270688
Provider Name (Legal Business Name): MILAIDY GONZALO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2119 10TH AVE N
LAKE WORTH BEACH FL
33461-3345
US

IV. Provider business mailing address

2812 KENTUCKY ST
WEST PALM BEACH FL
33406-4243
US

V. Phone/Fax

Practice location:
  • Phone: 561-444-2814
  • Fax: 561-444-2458
Mailing address:
  • Phone: 561-729-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-281963
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: