Provider Demographics
NPI:1891298295
Name:DIAGO-GOMEZ, MYRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:DIAGO-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 1:1411 NW 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313-6222
Mailing Address - Country:US
Mailing Address - Phone:954-806-2443
Mailing Address - Fax:
Practice Address - Street 1:1411 NW 60TH AVE
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313-6222
Practice Address - Country:US
Practice Address - Phone:954-806-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician