Provider Demographics
NPI:1720550700
Name:BREA-GOMEZ, CHARLYN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHARLYN
Middle Name:
Last Name:BREA-GOMEZ
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:CHARLYN
Other - Middle Name:
Other - Last Name:BREA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-920-7364
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-7364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028307235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist