Provider Demographics
NPI:1437614096
Name:GOMEZ, ROSA MARIA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:MARIA
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 1:11 GLEN EAGLES DR
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-4000
Mailing Address - Country:US
Mailing Address - Phone:646-270-8862
Mailing Address - Fax:
Practice Address - Street 1:11 GLEN EAGLES DR
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-4000
Practice Address - Country:US
Practice Address - Phone:646-270-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00356600101YM0800X
NJ37ACOO356600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty