Provider Demographics
NPI:1255641882
Name:HERNANDEZ-GOMEZ, MELISSA ANN
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:HERNANDEZ-GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:503 DAVIDSON ST
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-2430
Mailing Address - Country:US
Mailing Address - Phone:618-841-0898
Mailing Address - Fax:
Practice Address - Street 1:503 DAVIDSON ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-2430
Practice Address - Country:US
Practice Address - Phone:618-841-0898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-16
Last Update Date:2010-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2457498222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist