Provider Demographics
NPI:1134644008
Name:GAMBOA-SOSA, LIERUSKA
Entity Type:Individual
Prefix:
First Name:LIERUSKA
Middle Name:
Last Name:GAMBOA-SOSA
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 1:605 MONICA ROSE DR APT 1306
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-3470
Mailing Address - Country:US
Mailing Address - Phone:786-626-3562
Mailing Address - Fax:407-410-1442
Practice Address - Street 1:605 MONICA ROSE DR APT 1309
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-3470
Practice Address - Country:US
Practice Address - Phone:786-626-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty