Provider Demographics
NPI:1578078051
Name:GONZALEZ, LAZARA JULIET (BCBA)
Entity type:Individual
Prefix:
First Name:LAZARA
Middle Name:JULIET
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 CONNOR AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-3621
Mailing Address - Country:US
Mailing Address - Phone:787-368-9296
Mailing Address - Fax:
Practice Address - Street 1:3704 CONNOR AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-3621
Practice Address - Country:US
Practice Address - Phone:787-368-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2024-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-54607103K00000X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019556300Medicaid
FL102899600Medicaid