Provider Demographics
NPI:1962844019
Name:GOMEZ, IRENE (OTR)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4353 142ND ST
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2201
Mailing Address - Country:US
Mailing Address - Phone:773-771-7882
Mailing Address - Fax:
Practice Address - Street 1:2801 S LAWNDALE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4547
Practice Address - Country:US
Practice Address - Phone:773-456-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.003482225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist