Provider Demographics
NPI:1730315946
Name:GOMEZ, JUAN A (MS SP TEACHER)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:A
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MS SP TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 ALLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-6132
Mailing Address - Country:US
Mailing Address - Phone:347-879-7513
Mailing Address - Fax:347-879-7513
Practice Address - Street 1:1575 ALLERTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-6132
Practice Address - Country:US
Practice Address - Phone:347-879-7513
Practice Address - Fax:347-879-7513
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor