Provider Demographics
NPI:1548971641
Name:GOMEZ ALBERTUS, MABEL
Entity type:Individual
Prefix:
First Name:MABEL
Middle Name:
Last Name:GOMEZ ALBERTUS
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 1:155 CAMBRIA GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-6872
Mailing Address - Country:US
Mailing Address - Phone:863-512-4803
Mailing Address - Fax:
Practice Address - Street 1:155 CAMBRIA GROVE CIR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6872
Practice Address - Country:US
Practice Address - Phone:407-558-6874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician