Provider Demographics
NPI:1295515476
Name:GONZALEZ BENCOMO, DAYLIN
Entity type:Individual
Prefix:
First Name:DAYLIN
Middle Name:
Last Name:GONZALEZ BENCOMO
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 1:5100 LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-1054
Mailing Address - Country:US
Mailing Address - Phone:239-371-4091
Mailing Address - Fax:
Practice Address - Street 1:9160 FORUM CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7805
Practice Address - Country:US
Practice Address - Phone:239-544-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-262942106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician