Provider Demographics
NPI:1285876409
Name:GOMEZ, MANUEL O (MS, LMH,MCAP, CCM,)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:O
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MS, LMH,MCAP, CCM,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E CENTRAL AVE STE 340
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-6339
Mailing Address - Country:US
Mailing Address - Phone:863-412-8711
Mailing Address - Fax:877-340-0107
Practice Address - Street 1:141 E CENTRAL AVE STE 340
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-412-8711
Practice Address - Fax:877-340-0107
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLABC010814-215101YA0400X
FL6158101YP2500X
FL131096171M00000X
FL689259179171M00000X
FL11142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689259179Medicaid