Provider Demographics
NPI:1710291778
Name:GOMEZ, SANDRA
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
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 1:8619 75TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1828
Mailing Address - Country:US
Mailing Address - Phone:718-812-8542
Mailing Address - Fax:
Practice Address - Street 1:475 RIVERSIDE DRIVE
Practice Address - Street 2:SUITE 730
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10115-0797
Practice Address - Country:US
Practice Address - Phone:212-221-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency