Provider Demographics
NPI:1568736205
Name:GOMEZ-ORTA, VON MARIE
Entity Type:Individual
Prefix:
First Name:VON MARIE
Middle Name:
Last Name:GOMEZ-ORTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DIAMANTE S-13
Mailing Address - Street 2:VALLE DE CERRO GORDO
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957
Mailing Address - Country:UM
Mailing Address - Phone:787-667-3282
Mailing Address - Fax:
Practice Address - Street 1:S13 CALLE DIAMANTE
Practice Address - Street 2:VALLE DE CERRO GORDO
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00957-6848
Practice Address - Country:US
Practice Address - Phone:787-667-3282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2021-07-15
Deactivation Date:2020-09-14
Deactivation Code:
Reactivation Date:2021-07-15
Provider Licenses
StateLicense IDTaxonomies
PR19621104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker