Provider Demographics
NPI:1114440849
Name:GOMEZ, LOURDES TATIANA (RBT)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:TATIANA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 SW 66TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4837
Mailing Address - Country:US
Mailing Address - Phone:904-365-3110
Mailing Address - Fax:
Practice Address - Street 1:950 SW 66TH AVE APT 3
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4837
Practice Address - Country:US
Practice Address - Phone:904-365-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty