Provider Demographics
NPI:1568913200
Name:GONGORA RICARDO, MARTA
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:GONGORA RICARDO
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 1:2510 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-1106
Mailing Address - Country:US
Mailing Address - Phone:727-289-1164
Mailing Address - Fax:866-788-1127
Practice Address - Street 1:2510 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-1106
Practice Address - Country:US
Practice Address - Phone:727-289-1164
Practice Address - Fax:866-788-1127
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL193200000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health