Provider Demographics
NPI:1467688721
Name:GOMEZ, SUSIE M (MS SLP CCC)
Entity Type:Individual
Prefix:MRS
First Name:SUSIE
Middle Name:M
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MS SLP CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-2145
Mailing Address - Country:US
Mailing Address - Phone:361-275-1900
Mailing Address - Fax:361-275-8957
Practice Address - Street 1:960 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-2145
Practice Address - Country:US
Practice Address - Phone:361-275-1900
Practice Address - Fax:361-275-8957
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24744235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164704201Medicaid
TX164704201Medicaid