Provider Demographics
NPI:1932623162
Name:GOMEZ, MAGALY M
Entity Type:Individual
Prefix:
First Name:MAGALY
Middle Name:M
Last Name: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 1:13700 SW 147TH CIRCLE LN APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5751
Mailing Address - Country:US
Mailing Address - Phone:954-864-2507
Mailing Address - Fax:
Practice Address - Street 1:1250 SW 27TH AVE STE 402
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-4750
Practice Address - Country:US
Practice Address - Phone:305-642-5255
Practice Address - Fax:305-642-5255
Is Sole Proprietor?:No
Enumeration Date:2017-07-30
Last Update Date:2017-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12889101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health