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NPI Code Detail

MEDICARE: MARISSA GONZALES MA, BCBA, LBA

MEDICARE: MARISSA GONZALES MA, BCBA, LBA
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
1103K00000XBehavior Analyst3257TX

General Provider Information

NPI Number : 1740812056
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARISSA GONZALES MA, BCBA, LBA
Provider Business Mailing Address
First Line : 7108 S KANNER HWY
Second Line :
City : STUART
State : FL
Zip : 34997-7462
Country : US
Telephone Number : 855-832-6727
Fax Number :
Provider Business Practice Location Address
First Line : 700 N SAINT MARYS ST STE 1400
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78205-3535
Country : US
Telephone Number : 855-832-6727
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/05/2020
Last Update Date : 06/06/2023

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