Provider Demographics
NPI:1588307003
Name:VILLAVICENCIA GOMEZ, YENISLEY
Entity type:Individual
Prefix:
First Name:YENISLEY
Middle Name:
Last Name:VILLAVICENCIA GOMEZ
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 1:20922 SW 123RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-5748
Mailing Address - Country:US
Mailing Address - Phone:786-202-3655
Mailing Address - Fax:
Practice Address - Street 1:20922 SW 123RD CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-5748
Practice Address - Country:US
Practice Address - Phone:786-202-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-128886106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician