MEDICARE: LISSET TEJERA GOMEZ RBT-25-405139

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-25-405139	FL

General Provider Information

NPI Number	:	1770383721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISSET TEJERA GOMEZ RBT-25-405139

Provider Business Mailing Address
First Line	:	4757 ORANGE GROVE BLVD # D7
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-4597
Country	:	US
Telephone Number	:	239-878-9384
Fax Number	:

Provider Business Practice Location Address
First Line	:	4757 ORANGE GROVE BLVD # D7
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-4597
Country	:	US
Telephone Number	:	239-990-1465
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2025
Last Update Date	:	03/18/2025

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