Provider Demographics
NPI:1215537519
Name:GOMEZ HERNANDEZ, YAMILE
Entity Type:Individual
Prefix:
First Name:YAMILE
Middle Name:
Last Name:GOMEZ HERNANDEZ
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 1:1731 W 68TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4436
Mailing Address - Country:US
Mailing Address - Phone:786-598-6612
Mailing Address - Fax:
Practice Address - Street 1:1731 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4436
Practice Address - Country:US
Practice Address - Phone:786-598-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-135953106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty