Provider Demographics
NPI:1669847257
Name:GOMEZ, BRENDA G
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:G
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 1:1428 KNOTTY PINE DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-8843
Mailing Address - Country:US
Mailing Address - Phone:847-912-2237
Mailing Address - Fax:
Practice Address - Street 1:1428 KNOTTY PINE DR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-8843
Practice Address - Country:US
Practice Address - Phone:847-912-2237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter