Provider Demographics
NPI:1114525409
Name:GOMEZ, AGILDA
Entity type:Individual
Prefix:MS
First Name:AGILDA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7250 NW 177TH ST APT 206
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6238
Mailing Address - Country:US
Mailing Address - Phone:786-343-3012
Mailing Address - Fax:
Practice Address - Street 1:7250 NW 177TH ST APT 206
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-6238
Practice Address - Country:US
Practice Address - Phone:786-343-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-131868106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician