Healthcare Provider Details

I. General information

NPI: 1952248577
Provider Name (Legal Business Name): MARISOL GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 NORTH WICKHAM RD SUITE 13
MELBOURNE FL
32935-8307
US

IV. Provider business mailing address

4095 WATERLOO PL
MELBOURNE FL
32940-1278
US

V. Phone/Fax

Practice location:
  • Phone: 352-254-0233
  • Fax:
Mailing address:
  • Phone: 352-254-0233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-89617
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: