Provider Demographics
NPI:1972310837
Name:YUSTA GOMEZ, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:YUSTA 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 1:2706 W 72ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5420
Mailing Address - Country:US
Mailing Address - Phone:904-877-3344
Mailing Address - Fax:
Practice Address - Street 1:2706 W 72ND ST
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33016-5420
Practice Address - Country:US
Practice Address - Phone:904-877-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-14
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-398194106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst