Healthcare Provider Details

I. General information

NPI: 1497164164
Provider Name (Legal Business Name): DARRYL BRYAN GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S SEMINOLE AVE
MINNEOLA FL
34715-5520
US

IV. Provider business mailing address

405 S SEMINOLE AVE
MINNEOLA FL
34715-5520
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0212
  • Fax: 352-241-6361
Mailing address:
  • Phone: 352-394-0212
  • Fax: 352-241-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ 6737
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: