Healthcare Provider Details

I. General information

NPI: 1235800970
Provider Name (Legal Business Name): DIEGO GUMUCIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 COLLINS AVE APT 501
MIAMI BEACH FL
33139-4640
US

IV. Provider business mailing address

1255 COLLINS AVE APT 501
MIAMI BEACH FL
33139-4640
US

V. Phone/Fax

Practice location:
  • Phone: 415-900-9282
  • Fax:
Mailing address:
  • Phone: 415-900-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH19730
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: