Provider Demographics
NPI:1255853149
Name:GOMEZ, MACAELA JULIE (MOTR/L)
Entity Type:Individual
Prefix:MS
First Name:MACAELA
Middle Name:JULIE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 812
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-0812
Mailing Address - Country:US
Mailing Address - Phone:970-749-7001
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 10
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575-0010
Practice Address - Country:US
Practice Address - Phone:575-588-7297
Practice Address - Fax:575-588-0359
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3674225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist