Healthcare Provider Details

I. General information

NPI: 1720613029
Provider Name (Legal Business Name): LAURA GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA ALEJANDRA GOMEZ

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 10/17/2022
Certification Date: 10/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 BUCHANAN RD
DELRAY BEACH FL
33484-4218
US

IV. Provider business mailing address

5430 BUCHANAN RD
DELRAY BEACH FL
33484-4218
US

V. Phone/Fax

Practice location:
  • Phone: 305-927-0931
  • Fax:
Mailing address:
  • Phone: 305-927-0931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-21-13291
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-113035
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-62037
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: