Provider Demographics
NPI:1326784299
Name:GOMEZ, LIZANDRA
Entity Type:Individual
Prefix:
First Name:LIZANDRA
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 1:3708 SW 12TH PL
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-3411
Mailing Address - Country:US
Mailing Address - Phone:954-982-4154
Mailing Address - Fax:
Practice Address - Street 1:3708 SW 12TH PL
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-3411
Practice Address - Country:US
Practice Address - Phone:954-982-4154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-138391106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114128300Medicaid