Provider Demographics
NPI:1265201438
Name:GOMEZ, MAKALI (DPT)
Entity type:Individual
Prefix:
First Name:MAKALI
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 N 38TH ST UNIT 30
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-6318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:539 E GLENDALE AVE STE 105
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4900
Practice Address - Country:US
Practice Address - Phone:067-893-6472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-033405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty