Basic Information
Provider Information | |||||||||
NPI: | 1275970436 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMEZ | ||||||||
FirstName: | MARIANA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 193069 | ||||||||
Address2: |   | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009193069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877610036 | ||||||||
FaxNumber: | 7872925050 | ||||||||
Practice Location | |||||||||
Address1: | SANTURCE MEDICAL MALL OFIC 215 EDIF 1801 | ||||||||
Address2: |   | ||||||||
City: | SANTURCE | ||||||||
State: | PR | ||||||||
PostalCode: | 009364367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877725511 | ||||||||
FaxNumber: | 7877546359 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2013 | ||||||||
LastUpdateDate: | 05/29/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 108234 | TX | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.