Healthcare Provider Details

I. General information

NPI: 1174309314
Provider Name (Legal Business Name): IVIS C GUTIERREZ GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12719 SW 136TH ST APT 7105
MIAMI FL
33186-5283
US

IV. Provider business mailing address

3103 W POWHATAN AVE
TAMPA FL
33614-5956
US

V. Phone/Fax

Practice location:
  • Phone: 813-485-1514
  • Fax:
Mailing address:
  • Phone: 813-485-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-26-17186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: