MEDICARE: IBET LOPEZ GOMEZ

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	106S00000X	Behavior Technician	RBT-20-116525	FL

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	:	1316519820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IBET LOPEZ GOMEZ

Provider Business Mailing Address
First Line	:	5040 PALM HILL DR APT 135
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-5681
Country	:	US
Telephone Number	:	561-603-9352
Fax Number	:

Provider Business Practice Location Address
First Line	:	4965 CHACHA CT APT 39
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-5669
Country	:	US
Telephone Number	:	561-603-9352
Fax Number	:

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

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	07/16/2025

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