MEDICARE: LUISA V BRICENO GONZALEZ

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	103K00000X	Behavior Analyst		FL

General Provider Information

NPI Number	:	1235986142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUISA V BRICENO GONZALEZ

Provider Business Mailing Address
First Line	:	2505 BLOODS GROVE CIR # A
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-5305
Country	:	US
Telephone Number	:	407-792-4999
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 BLOODS GROVE CIR
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-5305
Country	:	US
Telephone Number	:	561-579-8922
Fax Number	:

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

Provider Enumeration Date	:	04/30/2024
Last Update Date	:	04/30/2024

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