Provider Demographics
NPI:1417615121
Name:GOMEZ-LOSTALO, CAROLINA (MS)
Entity Type:Individual
Prefix:
First Name:CAROLINA
Middle Name:
Last Name:GOMEZ-LOSTALO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25060 SW 121ST PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5985
Mailing Address - Country:US
Mailing Address - Phone:786-873-9922
Mailing Address - Fax:
Practice Address - Street 1:13155 SW 134TH ST STE 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4488
Practice Address - Country:US
Practice Address - Phone:786-842-3624
Practice Address - Fax:844-905-1472
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
FLBACB715333106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health