Provider Demographics
NPI:1902313067
Name:PERDIGON GOMEZ, INGRID MICHELLE (MS)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:MICHELLE
Last Name:PERDIGON GOMEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 DEEP EDDY AVE.
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703
Mailing Address - Country:US
Mailing Address - Phone:512-469-0889
Mailing Address - Fax:512-469-6002
Practice Address - Street 1:508 DEEP EDDY AVE.
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703
Practice Address - Country:US
Practice Address - Phone:512-469-0889
Practice Address - Fax:512-469-6002
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional