Provider Demographics
NPI:1043823255
Name:GONZALEZ, GINNA (MS)
Entity type:Individual
Prefix:
First Name:GINNA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15425 SW 32ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4727
Mailing Address - Country:US
Mailing Address - Phone:786-925-0023
Mailing Address - Fax:
Practice Address - Street 1:2645 EXECUTIVE PARK DR STE 149
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3624
Practice Address - Country:US
Practice Address - Phone:786-925-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherN/A