Provider Demographics
NPI:1447765334
Name:GOMEZ, ANIA
Entity Type:Individual
Prefix:
First Name:ANIA
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 1:15435 SW 75TH CIRCLE LN APT 9-102
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15435 SW 75TH CIRCLE LN APT 9-102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2079
Practice Address - Country:US
Practice Address - Phone:786-548-7972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty