Provider Demographics
NPI:1265251839
Name:RODRIGUEZ GOMEZ, YIRY ERNESTO
Entity type:Individual
Prefix:
First Name:YIRY
Middle Name:ERNESTO
Last Name:RODRIGUEZ GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 EBB TIDE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6268
Mailing Address - Country:US
Mailing Address - Phone:386-517-4917
Mailing Address - Fax:
Practice Address - Street 1:59 EBB TIDE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-6268
Practice Address - Country:US
Practice Address - Phone:386-517-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-380643106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician