Provider Demographics
NPI:1467796110
Name:GOMEZ, MARIVIC RAMORES
Entity Type:Individual
Prefix:MRS
First Name:MARIVIC
Middle Name:RAMORES
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARIVIC
Other - Middle Name:PENA
Other - Last Name:RAMORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2503 W SPRINGFIELD AVE APT G1
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2834
Mailing Address - Country:US
Mailing Address - Phone:954-798-3774
Mailing Address - Fax:
Practice Address - Street 1:2503 W SPRINGFIELD AVE APT G1
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2834
Practice Address - Country:US
Practice Address - Phone:954-798-3774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019062225100000X
TX1224821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist