Healthcare Provider Details

I. General information

NPI: 1154282572
Provider Name (Legal Business Name): LUIS GOMEZ REYES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/25/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34984-5108
US

IV. Provider business mailing address

455 SW KESTOR DR
PORT SAINT LUCIE FL
34953-5520
US

V. Phone/Fax

Practice location:
  • Phone: 772-202-0173
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-485980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: