Provider Demographics
NPI:1528599628
Name:FERNANDEZ GOMEZ, YAIMARA D
Entity Type:Individual
Prefix:
First Name:YAIMARA
Middle Name:D
Last Name:FERNANDEZ 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 1:23187 SW 108TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-7536
Mailing Address - Country:US
Mailing Address - Phone:786-548-6774
Mailing Address - Fax:
Practice Address - Street 1:23187 SW 108TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-7536
Practice Address - Country:US
Practice Address - Phone:786-548-6774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21788101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health