Provider Demographics
NPI:1992218069
Name:GOMEZ, MIRIAN
Entity Type:Individual
Prefix:
First Name:MIRIAN
Middle Name:
Last Name: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 1:5614 FLAGLER ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33023-2316
Mailing Address - Country:US
Mailing Address - Phone:954-643-3848
Mailing Address - Fax:
Practice Address - Street 1:5614 FLAGLER ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33023-2316
Practice Address - Country:US
Practice Address - Phone:954-643-3848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health