Healthcare Provider Details

I. General information

NPI: 1922357227
Provider Name (Legal Business Name): DAVID GOMEZ LMHC, BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16071 MICELLI DR
WINTER GARDEN FL
34787-1821
US

IV. Provider business mailing address

7830 NW 161ST TER
MIAMI LAKES FL
33016-6677
US

V. Phone/Fax

Practice location:
  • Phone: 305-607-2896
  • Fax:
Mailing address:
  • Phone: 305-607-2896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11833858
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 13328
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: