Provider Demographics
NPI:1568597953
Name:GOMEZ LUACES, LOURDES MARIA (CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:LOURDES
Middle Name:MARIA
Last Name:GOMEZ LUACES
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:MRS
Other - First Name:LOURDES
Other - Middle Name:MARIA
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCCSLP
Mailing Address - Street 1:6508 GUNN HIGHWAY
Mailing Address - Street 2:INDEPENDENT LIVING INC
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4022
Mailing Address - Country:US
Mailing Address - Phone:813-963-6923
Mailing Address - Fax:813-264-0768
Practice Address - Street 1:6508 GUNN HIGHWAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4022
Practice Address - Country:US
Practice Address - Phone:813-963-6923
Practice Address - Fax:813-264-0768
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5670235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist