Provider Demographics
NPI:1275974792
Name:GOMEZ, MARY R (LADAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 CENTRAL AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1139
Mailing Address - Country:US
Mailing Address - Phone:505-247-4622
Mailing Address - Fax:505-247-1373
Practice Address - Street 1:1611 CENTRAL AVE. NW
Practice Address - Street 2:
Practice Address - City:ALBUQ
Practice Address - State:NM
Practice Address - Zip Code:87104
Practice Address - Country:US
Practice Address - Phone:505-247-4622
Practice Address - Fax:505-247-1373
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3678101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)