Provider Demographics
NPI:1235908732
Name:GOMEZ, YEILIS
Entity Type:Individual
Prefix:
First Name:YEILIS
Middle Name:
Last Name:GOMEZ
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 1:7014 SW COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34269-3416
Mailing Address - Country:US
Mailing Address - Phone:863-444-5162
Mailing Address - Fax:
Practice Address - Street 1:18245 PAULSON DR
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-1019
Practice Address - Country:US
Practice Address - Phone:813-528-7048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1042575106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician