Provider Demographics
NPI:1215783113
Name:RODRIGUEZ GOMEZ, LYEN (RBT)
Entity type:Individual
Prefix:
First Name:LYEN
Middle Name:
Last Name:RODRIGUEZ GOMEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17715 NW 55TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-3527
Mailing Address - Country:US
Mailing Address - Phone:786-709-3467
Mailing Address - Fax:
Practice Address - Street 1:13195 SW 134TH ST STE 101-103
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4499
Practice Address - Country:US
Practice Address - Phone:786-227-6830
Practice Address - Fax:786-524-2413
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-334247106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician