Healthcare Provider Details

I. General information

NPI: 1174059117
Provider Name (Legal Business Name): NIDIA GONZALEZ RN, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1469 NW 36TH ST
MIAMI FL
33142-5557
US

IV. Provider business mailing address

5925 SW 94TH AVE
MIAMI FL
33173-1570
US

V. Phone/Fax

Practice location:
  • Phone: 305-635-0366
  • Fax:
Mailing address:
  • Phone: 305-761-2454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9256021
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: