Provider Demographics
NPI:1578820049
Name:GOMEZ, ANGELICA ELIZABETH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:ELIZABETH
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1317
Mailing Address - Country:US
Mailing Address - Phone:708-769-9530
Mailing Address - Fax:
Practice Address - Street 1:1219 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-4046
Practice Address - Country:US
Practice Address - Phone:888-584-7888
Practice Address - Fax:708-531-7936
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005103225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant