Provider Demographics
NPI:1356965040
Name:CEPERO GOMEZ, YANSEL
Entity type:Individual
Prefix:
First Name:YANSEL
Middle Name:
Last Name:CEPERO 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 1:7346 COLDSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2204
Mailing Address - Country:US
Mailing Address - Phone:407-952-8394
Mailing Address - Fax:
Practice Address - Street 1:7346 COLDSTREAM DR
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2204
Practice Address - Country:US
Practice Address - Phone:407-952-8394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-120233106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty