Provider Demographics
NPI:1518478577
Name:GOMEZ, GRISELDA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 BOB OFARRELL LN
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-4512
Mailing Address - Country:US
Mailing Address - Phone:224-538-9901
Mailing Address - Fax:
Practice Address - Street 1:649 BARRON BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1343
Practice Address - Country:US
Practice Address - Phone:847-223-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14145719261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech