Provider Demographics
NPI:1265041065
Name:GACIO GONZALEZ, YAHIMA
Entity Type:Individual
Prefix:
First Name:YAHIMA
Middle Name:
Last Name:GACIO GONZALEZ
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 1:1430 SW 126TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2310
Mailing Address - Country:US
Mailing Address - Phone:786-775-7305
Mailing Address - Fax:
Practice Address - Street 1:1430 SW 126TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2310
Practice Address - Country:US
Practice Address - Phone:786-775-7305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-118561106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9140860054OtherAETNA