Provider Demographics
NPI:1063682797
Name:GOMEZ, EDUARDO
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDUARDO
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1406 61ST ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-1760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6801 HIGH GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7585
Practice Address - Country:US
Practice Address - Phone:630-734-4588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057000770224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant