Provider Demographics
NPI:1396265575
Name:FERNANDEZ GOMEZ, ENRIQUE LAZARO
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:LAZARO
Last Name:FERNANDEZ GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14611 SW 88TH ST
Mailing Address - Street 2:BUILDING L APT 206
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14611 SW 88TH ST APT 206
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1021
Practice Address - Country:US
Practice Address - Phone:786-266-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-69347106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty