Healthcare Provider Details

I. General information

NPI: 1295200079
Provider Name (Legal Business Name): ENRIQUE LUIS GONZALEZ QBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E NASA BLVD
MELBOURNE FL
32901-1900
US

IV. Provider business mailing address

2032 BRIARCLIFF CIR
MOUNT DORA FL
32757
US

V. Phone/Fax

Practice location:
  • Phone: 321-372-6813
  • Fax: 321-764-6434
Mailing address:
  • Phone: 407-797-2223
  • Fax: 321-764-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number19573
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-64913
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: