Provider Demographics
NPI:1922607639
Name:GOMEZ BOHORQUEZ, KANAIME
Entity Type:Individual
Prefix:
First Name:KANAIME
Middle Name:
Last Name:GOMEZ BOHORQUEZ
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 1:12310 SW 151ST ST APT 180
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6119
Mailing Address - Country:US
Mailing Address - Phone:786-451-0072
Mailing Address - Fax:
Practice Address - Street 1:12310 SW 151ST ST APT 180
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6119
Practice Address - Country:US
Practice Address - Phone:786-451-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician