MEDICARE: LISSETTE GOMEZ FERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-19-34626	FL
2	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194260463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISSETTE GOMEZ FERNANDEZ

Provider Business Mailing Address
First Line	:	530 SE 11TH CT
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-2682
Country	:	US
Telephone Number	:	786-867-0060
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 SE 11TH CT
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-2682
Country	:	US
Telephone Number	:	786-867-0060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2016
Last Update Date	:	03/11/2026

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