Provider Demographics
NPI:1871368761
Name:GOMEZ, BIANCA LETICIA
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:LETICIA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 FANNIN ST APT 2614
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-7658
Mailing Address - Country:US
Mailing Address - Phone:956-324-3282
Mailing Address - Fax:
Practice Address - Street 1:1617 FANNIN ST APT 2614
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-7658
Practice Address - Country:US
Practice Address - Phone:956-324-3282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBCAB980104106S00000X
TX1155122119101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician