MEDICARE: DR. KETTY PATINO GONZALEZ PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PY0005873	FL
2	103TC2200X	Clinical Child & Adolescent Psychologist	PY0005873	FL

General Provider Information

NPI Number	:	1053519900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KETTY PATINO GONZALEZ PH.D.

Provider Business Mailing Address
First Line	:	5915 PONCE DE LEON BLVD STE 49
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2435
Country	:	US
Telephone Number	:	305-668-0355
Fax Number	:

Provider Business Practice Location Address
First Line	:	5915 PONCE DE LEON BLVD STE 49
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2435
Country	:	US
Telephone Number	:	305-668-0355
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	09/11/2025

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