Provider Demographics
NPI:1093214520
Name:GOMEZ, BRIAN JESSE
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JESSE
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 FISHERMANS TER
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:IL
Mailing Address - Zip Code:60534-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4220 FISHERMANS TER
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534-1402
Practice Address - Country:US
Practice Address - Phone:708-612-2756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician