Healthcare Provider Details

I. General information

NPI: 1134801848
Provider Name (Legal Business Name): LIZ MARIAM VIGO GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SW 72ND ST STE 467
MIAMI FL
33173-3028
US

IV. Provider business mailing address

3423 W 80TH ST APT 108
HIALEAH FL
33018-7563
US

V. Phone/Fax

Practice location:
  • Phone: 786-536-7213
  • Fax: 786-528-3059
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-274149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: