Provider Demographics
NPI:1457934416
Name:GOMES FERNANDEZ, ANA BEATRIZ
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:BEATRIZ
Last Name:GOMES FERNANDEZ
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 1:17466 NW 91ST CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-6699
Mailing Address - Country:US
Mailing Address - Phone:786-448-3120
Mailing Address - Fax:
Practice Address - Street 1:10261 SW 72ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3023
Practice Address - Country:US
Practice Address - Phone:786-773-3654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB622379106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician