Provider Demographics
NPI:1447094933
Name:PUPO GONZALEZ, JORGE LUIS (RBT)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:PUPO GONZALEZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-9004
Mailing Address - Country:US
Mailing Address - Phone:281-323-0119
Mailing Address - Fax:
Practice Address - Street 1:12490 NE 7TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5660
Practice Address - Country:US
Practice Address - Phone:786-709-8403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty