Provider Demographics
NPI:1437579935
Name:GOMEZ, ALTA
Entity Type:Individual
Prefix:
First Name:ALTA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 LYNNEHAVEN DR
Mailing Address - Street 2:APT.L
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-4167
Mailing Address - Country:US
Mailing Address - Phone:240-500-6406
Mailing Address - Fax:
Practice Address - Street 1:508 LYNNEHAVEN DR
Practice Address - Street 2:APT. L
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-4167
Practice Address - Country:US
Practice Address - Phone:240-500-6406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07030225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist