Healthcare Provider Details

I. General information

NPI: 1972169662
Provider Name (Legal Business Name): REINALDO GONZALEZ BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 S RIO GRANDE AVE STE 102
ORLANDO FL
32809-4650
US

IV. Provider business mailing address

6000 S RIO GRANDE AVE STE 102
ORLANDO FL
32809-4650
US

V. Phone/Fax

Practice location:
  • Phone: 407-982-7718
  • Fax:
Mailing address:
  • Phone: 407-982-7718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: