Provider Demographics
NPI:1649744426
Name:GOMEZ CASTILLO, FABIANA V (RBT)
Entity Type:Individual
Prefix:
First Name:FABIANA
Middle Name:V
Last Name:GOMEZ CASTILLO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4128 WELLINGTON WOODS CIR APT 104
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2763
Mailing Address - Country:US
Mailing Address - Phone:863-254-9120
Mailing Address - Fax:
Practice Address - Street 1:3501 W VINE ST STE 115
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4644
Practice Address - Country:US
Practice Address - Phone:407-483-3074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-70673106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty