Basic Information
| Provider Information | |||||||||
| NPI: | 1720425085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | YANED | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2632 SW PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349532845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728738811 | ||||||||
| FaxNumber: | 7728738800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW SYLVESTER LN | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349843605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7727779265 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106S00000X | N |
No ID Information.