Provider Demographics
NPI:1205683612
Name:GOMEZ SANTISTEBAN, LANDY O
Entity type:Individual
Prefix:
First Name:LANDY
Middle Name:O
Last Name:GOMEZ SANTISTEBAN
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 1:4992 REGINA CT
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-9165
Mailing Address - Country:US
Mailing Address - Phone:561-709-1779
Mailing Address - Fax:
Practice Address - Street 1:4992 REGINA CT
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-9165
Practice Address - Country:US
Practice Address - Phone:561-709-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-343375106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician