Provider Demographics
NPI:1891339875
Name:GOMES, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GOMES
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 1:5804 PECKING STONE ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6866
Mailing Address - Country:US
Mailing Address - Phone:301-401-2584
Mailing Address - Fax:
Practice Address - Street 1:351 W CAMDEN ST STE 500
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-7912
Practice Address - Country:US
Practice Address - Phone:667-214-1757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00009452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer