Provider Demographics
NPI:1467668699
Name:GOMBATZ, MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GOMBATZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:RIVA
Mailing Address - State:MD
Mailing Address - Zip Code:21140-1433
Mailing Address - Country:US
Mailing Address - Phone:410-269-7789
Mailing Address - Fax:410-298-8225
Practice Address - Street 1:353 BERKSHIRE DR
Practice Address - Street 2:
Practice Address - City:RIVA
Practice Address - State:MD
Practice Address - Zip Code:21140-1433
Practice Address - Country:US
Practice Address - Phone:410-269-7789
Practice Address - Fax:410-298-8225
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical