Provider Demographics
NPI:1114662582
Name:GOMEZ, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13370 SW 91ST TER
Mailing Address - Street 2:UNIT A
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-1613
Mailing Address - Country:US
Mailing Address - Phone:305-778-9523
Mailing Address - Fax:
Practice Address - Street 1:14221 SW 120TH ST STE 214
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4224
Practice Address - Country:US
Practice Address - Phone:786-452-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-01
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-204056106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician