Provider Demographics
NPI:1477306181
Name:GUERRA GOMEZ, DEIVIS DANIEL
Entity Type:Individual
Prefix:
First Name:DEIVIS
Middle Name:DANIEL
Last Name:GUERRA GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-4244
Mailing Address - Country:US
Mailing Address - Phone:786-417-5340
Mailing Address - Fax:
Practice Address - Street 1:3621 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-4244
Practice Address - Country:US
Practice Address - Phone:786-417-5340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-338770106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician