Provider Demographics
NPI:1083447569
Name:GOMEZ EXPOSITO, MARIO RAFAEL
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:RAFAEL
Last Name:GOMEZ EXPOSITO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W 72ND ST APT 202
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3837
Mailing Address - Country:US
Mailing Address - Phone:305-876-4029
Mailing Address - Fax:
Practice Address - Street 1:1420 W 72ND ST APT 202
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3837
Practice Address - Country:US
Practice Address - Phone:305-876-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24366193106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician