Provider Demographics
NPI:1437459724
Name:GOMEZ, MAGNOLIA (SP ED)
Entity Type:Individual
Prefix:
First Name:MAGNOLIA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:SP ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E 173RD ST APT 6E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7862
Mailing Address - Country:US
Mailing Address - Phone:917-232-1122
Mailing Address - Fax:
Practice Address - Street 1:221 E 173RD ST APT 6E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7862
Practice Address - Country:US
Practice Address - Phone:917-232-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY437272101171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor