Provider Demographics
NPI:1396626529
Name:DE LA OSA GOMEZ, THALIA
Entity type:Individual
Prefix:
First Name:THALIA
Middle Name:
Last Name:DE LA OSA 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 1:3730 METRO PKWY APT 1237
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-7480
Mailing Address - Country:US
Mailing Address - Phone:786-442-9952
Mailing Address - Fax:
Practice Address - Street 1:9020 SW 137TH AVE # 111
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1427
Practice Address - Country:US
Practice Address - Phone:786-615-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-332635106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician