Provider Demographics
NPI:1710535810
Name:GOMEZ, MARISSA ALISHA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ALISHA
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:PO BOX 584
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023-0584
Mailing Address - Country:US
Mailing Address - Phone:575-342-2530
Mailing Address - Fax:
Practice Address - Street 1:53 COLEMAN DR
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-8954
Practice Address - Country:US
Practice Address - Phone:575-342-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-01
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician