Provider Demographics
NPI:1730739962
Name:GOMEZ GAVIRIA, SANDRA VERONICA (REGISTERED BEHAVIOR)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:VERONICA
Last Name:GOMEZ GAVIRIA
Suffix:
Gender:F
Credentials:REGISTERED BEHAVIOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7520 NW 175TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-7149
Mailing Address - Country:US
Mailing Address - Phone:305-205-3663
Mailing Address - Fax:
Practice Address - Street 1:7520 NW 175TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-7149
Practice Address - Country:US
Practice Address - Phone:305-205-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-1855400106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician