Provider Demographics
NPI:1235711615
Name:GOMEZ GUERRA, YENISET A
Entity Type:Individual
Prefix:
First Name:YENISET
Middle Name:A
Last Name:GOMEZ GUERRA
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 1:4556 JILL PL
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-4449
Mailing Address - Country:US
Mailing Address - Phone:702-461-1448
Mailing Address - Fax:
Practice Address - Street 1:4556 JILL PL
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-4449
Practice Address - Country:US
Practice Address - Phone:702-461-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-156699106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician