Provider Demographics
NPI:1861908030
Name:GOMEZ, REGINA MARGARITA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARGARITA
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 1:8031 TYSON OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3941
Mailing Address - Country:US
Mailing Address - Phone:571-212-6879
Mailing Address - Fax:
Practice Address - Street 1:6563 EDSALL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151
Practice Address - Country:US
Practice Address - Phone:703-354-0000
Practice Address - Fax:703-354-0000
Is Sole Proprietor?:No
Enumeration Date:2017-12-24
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001097103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst