Provider Demographics
NPI:1437859550
Name:GOMEZ LEON, CORINA ALEXANDRA
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:ALEXANDRA
Last Name:GOMEZ LEON
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 1:2755 W ATLANTIC AVE APT A103
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-4462
Mailing Address - Country:US
Mailing Address - Phone:305-407-0399
Mailing Address - Fax:
Practice Address - Street 1:2755 W ATLANTIC AVE APT A103
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-4462
Practice Address - Country:US
Practice Address - Phone:305-407-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21846101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health