Provider Demographics
NPI:1003676602
Name:GOMEZ GONZALEZ, KATIA
Entity Type:Individual
Prefix:
First Name:KATIA
Middle Name:
Last Name:GOMEZ GONZALEZ
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 1:6504 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-1502
Mailing Address - Country:US
Mailing Address - Phone:813-952-6775
Mailing Address - Fax:
Practice Address - Street 1:6504 N 31ST ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-1502
Practice Address - Country:US
Practice Address - Phone:813-952-6775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-334984106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician