Provider Demographics
NPI:1225186786
Name:GOMEZ, DORA SANDRA (BA, MS)
Entity Type:Individual
Prefix:MS
First Name:DORA
Middle Name:SANDRA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:BA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 CLARENCES RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7682
Mailing Address - Country:US
Mailing Address - Phone:505-864-0326
Mailing Address - Fax:
Practice Address - Street 1:38 CLARENCES RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7682
Practice Address - Country:US
Practice Address - Phone:505-864-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1273235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ9842Medicaid