Basic Information
| Provider Information | |||||||||
| NPI: | 1578078051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | LAZARA | ||||||||
| MiddleName: | JULIET | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 MAITLAND CENTER PKWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075744629 | ||||||||
| FaxNumber: | 4075743091 | ||||||||
| Practice Location | |||||||||
| Address1: | 1820 ARMSTRONG BLVD | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347412589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078523300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2017 | ||||||||
| LastUpdateDate: | 05/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y | 103TC1900X | N | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 019556300 | 05 | FL | MEDICAID |