Provider Demographics
NPI:1659092930
Name:GOMEZ, CLARISSA MARIE
Entity Type:Individual
Prefix:MISS
First Name:CLARISSA
Middle Name:MARIE
Last Name:GOMEZ
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 1:24340 APPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2276
Mailing Address - Country:US
Mailing Address - Phone:630-415-4787
Mailing Address - Fax:
Practice Address - Street 1:24340 APPLE TREE LN
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-2276
Practice Address - Country:US
Practice Address - Phone:630-415-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer