Healthcare Provider Details

I. General information

NPI: 1134046352
Provider Name (Legal Business Name): ODELAISY GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 SW PORT ST LUCIE BLVD APT 101
PORT ST LUCIE FL
34984-5081
US

IV. Provider business mailing address

191 SW PORT ST LUCIE BLVD APT 101
PORT ST LUCIE FL
34984-5081
US

V. Phone/Fax

Practice location:
  • Phone: 862-240-6960
  • Fax:
Mailing address:
  • Phone: 862-240-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: