Provider Demographics
NPI:1285438796
Name:GOMEZ, MARCIA S
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:S
Last Name:GOMEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 PRESTON WOODS DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7872
Mailing Address - Country:US
Mailing Address - Phone:954-274-9150
Mailing Address - Fax:
Practice Address - Street 1:4606 PRESTON WOODS DR
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-7872
Practice Address - Country:US
Practice Address - Phone:954-274-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-311401106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician