Provider Demographics
NPI:1619368446
Name:GOMEZ, MARIA LAURA (MED - BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:LAURA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MED - BCBA
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:LAURA
Other - Last Name:PRIETO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED - BCBA
Mailing Address - Street 1:1402 S CUSTER RD STE 601
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75072-1453
Mailing Address - Country:US
Mailing Address - Phone:214-842-8840
Mailing Address - Fax:972-465-9319
Practice Address - Street 1:1402 S CUSTER RD STE 601
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75072-1453
Practice Address - Country:US
Practice Address - Phone:214-842-8840
Practice Address - Fax:972-465-9319
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-16
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2354103K00000X
TX1-16-23704103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX22173796OtherDL