Provider Demographics
NPI:1326862079
Name:GOMEZ SIMPSON, TANIA
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:GOMEZ SIMPSON
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 1:8555 BERNWOOD COVE LOOP APT 101
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-8144
Mailing Address - Country:US
Mailing Address - Phone:786-443-3213
Mailing Address - Fax:
Practice Address - Street 1:8555 BERNWOOD COVE LOOP APT 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-8144
Practice Address - Country:US
Practice Address - Phone:786-443-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-157564106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician