Provider Demographics
NPI:1134626609
Name:GOMORI, CHELSEA
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:GOMORI
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 1:15506 DUPAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6021
Mailing Address - Country:US
Mailing Address - Phone:313-702-8195
Mailing Address - Fax:
Practice Address - Street 1:803 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7027
Practice Address - Country:US
Practice Address - Phone:805-735-3714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16794225X00000X
MI5201009440225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist