Provider Demographics
NPI:1235986142
Name:BRICENO GONZALEZ, LUISA V
Entity type:Individual
Prefix:
First Name:LUISA
Middle Name:V
Last Name:BRICENO GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 BLOODS GROVE CIR # A
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-5305
Mailing Address - Country:US
Mailing Address - Phone:407-792-4999
Mailing Address - Fax:
Practice Address - Street 1:2505 BLOODS GROVE CIR
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-5305
Practice Address - Country:US
Practice Address - Phone:561-579-8922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty