Basic Information
| Provider Information | |||||||||
| NPI: | 1568009850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | LINET | ||||||||
| MiddleName: | |||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 E NASA BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213726813 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Practice Location | |||||||||
| Address1: | 5830 US HIGHWAY 1 STE 104 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329555704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213726813 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2019 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-93287 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 104970200 | 05 | FL | MEDICAID |