Healthcare Provider Details

I. General information

NPI: 1295200079
Provider Name (Legal Business Name): ENRIQUE LUIS GONZALEZ QBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 DOWD CIR STE A
PINEHURST NC
28374-7932
US

IV. Provider business mailing address

2032 BRIARCLIFF CIR
MOUNT DORA FL
32757-6964
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-2609
  • Fax:
Mailing address:
  • Phone: 407-797-2223
  • Fax: 321-764-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number19573
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: