MEDICARE: CLARA IVON JORGE 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	103K00000X	Behavior Analyst	1-23-65741	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	:	1972020030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARA IVON JORGE GOMEZ

Provider Business Mailing Address
First Line	:	8975 OKEECHOBEE BLVD APT 303
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-5133
Country	:	US
Telephone Number	:	561-260-6871
Fax Number	:

Provider Business Practice Location Address
First Line	:	8975 OKEECHOBEE BLVD APT 303
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-5133
Country	:	US
Telephone Number	:	561-260-6871
Fax Number	:

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

Provider Enumeration Date	:	08/29/2017
Last Update Date	:	06/13/2023

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