Provider Demographics
NPI:1922629161
Name:GOMEZ, MEWW (LMBT)
Entity Type:Individual
Prefix:
First Name:MEWW
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 EXECUTIVE CENTER DR STE 350
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8847
Mailing Address - Country:US
Mailing Address - Phone:704-323-6718
Mailing Address - Fax:
Practice Address - Street 1:5701 EXECUTIVE CENTER DR STE 350
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8847
Practice Address - Country:US
Practice Address - Phone:704-323-6718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019008213225700000X
NC17657225700000X
249225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0019008213OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONALS
NC17657OtherNORTH CAROLINA BOARD OF MASSAGE AND BODYWORK THERAPY
NC249OtherNORTH CAROLINA BOARD OF MASSAGE AND BODYWORK THERAPY ESTABLISHMENT LICENSE