Provider Demographics
NPI:1083884613
Name:GOMER, DANIELLE LATRICIA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:LATRICIA
Last Name:GOMER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:DANIELLE
Other - Middle Name:LATRICIA
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:606 CANNON STREET
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620
Mailing Address - Country:US
Mailing Address - Phone:410-810-2957
Mailing Address - Fax:
Practice Address - Street 1:606 CANNON STREET
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620
Practice Address - Country:US
Practice Address - Phone:410-810-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2827261QP2000X
DEJ2-0000642261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy