MEDICARE: YISELL GEORGINA BENCOMO GONZALEZ

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	24-376239	FL

General Provider Information

NPI Number	:	1871320168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YISELL GEORGINA BENCOMO GONZALEZ

Provider Business Mailing Address
First Line	:	11101 NW 24TH ST
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-3644
Country	:	US
Telephone Number	:	954-419-7164
Fax Number	:

Provider Business Practice Location Address
First Line	:	11101 NW 24TH ST
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-3644
Country	:	US
Telephone Number	:	954-419-7164
Fax Number	:

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

Provider Enumeration Date	:	09/19/2024
Last Update Date	:	09/19/2024

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Directions to “ YISELL GEORGINA BENCOMO GONZALEZ ” Practice Location

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