Provider Demographics
NPI:1710514807
Name:PEREZ GOMEZ, LEWIS R
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:R
Last Name:PEREZ GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P41 CALLE 16
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-3100
Mailing Address - Country:US
Mailing Address - Phone:787-486-6032
Mailing Address - Fax:
Practice Address - Street 1:P41 CALLE 16
Practice Address - Street 2:
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-3100
Practice Address - Country:US
Practice Address - Phone:787-486-6032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6541103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist