Provider Demographics
NPI:1336275114
Name:GOMBA, MARIE T (MSW , LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:T
Last Name:GOMBA
Suffix:
Gender:F
Credentials:MSW , LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 RIVA RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7427
Mailing Address - Country:US
Mailing Address - Phone:410-222-5000
Mailing Address - Fax:
Practice Address - Street 1:2644 RIVA RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7427
Practice Address - Country:US
Practice Address - Phone:410-222-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MD070771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD160804OtherVALUE OPTIONS
MDR731 0005OtherCAREFIRST BLUECROSS BLUES