Provider Demographics
NPI:1043073620
Name:GONZALEZ BERNAL, YAIMA
Entity Type:Individual
Prefix:
First Name:YAIMA
Middle Name:
Last Name:GONZALEZ BERNAL
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 1:3232 CR 528
Mailing Address - Street 2:
Mailing Address - City:SUMTERVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:33585-5206
Mailing Address - Country:US
Mailing Address - Phone:407-731-5964
Mailing Address - Fax:
Practice Address - Street 1:13035 W LINEBAUGH AVE STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4481
Practice Address - Country:US
Practice Address - Phone:813-305-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician