Provider Demographics
NPI:1932984283
Name:GOMEZ, WILDER RENATO
Entity Type:Individual
Prefix:
First Name:WILDER
Middle Name:RENATO
Last Name: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 1:4022 NW 181ST LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-3430
Mailing Address - Country:US
Mailing Address - Phone:786-898-2504
Mailing Address - Fax:
Practice Address - Street 1:440 SAWGRASS CORPORATE PKWY STE 106
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6236
Practice Address - Country:US
Practice Address - Phone:954-745-1112
Practice Address - Fax:954-745-1120
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician