Provider Demographics
NPI:1154812980
Name:GOMIS, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:GOMIS
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 1:1463 OAKFIELD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-3893
Mailing Address - Country:US
Mailing Address - Phone:813-438-8902
Mailing Address - Fax:813-438-8903
Practice Address - Street 1:1463 OAKFIELD DR STE 102
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-3893
Practice Address - Country:US
Practice Address - Phone:813-438-8902
Practice Address - Fax:813-438-8903
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician