Healthcare Provider Details

I. General information

NPI: 1942143193
Provider Name (Legal Business Name): KEVIN JESUS GONZALEZ JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 SW 79TH AVE APT 62
MIAMI FL
33155-6735
US

IV. Provider business mailing address

777 NW 72ND AVE STE 1083
MIAMI FL
33126-3176
US

V. Phone/Fax

Practice location:
  • Phone: 786-438-6315
  • Fax:
Mailing address:
  • Phone: 786-490-6307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-526187
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: