Provider Demographics
NPI:1326647462
Name:GOMEZ, MAYRA F (COTA)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:F
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 72ND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5471
Mailing Address - Country:US
Mailing Address - Phone:201-491-2160
Mailing Address - Fax:
Practice Address - Street 1:612 72ND ST APT 2
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5471
Practice Address - Country:US
Practice Address - Phone:201-491-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09162000224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant