Provider Demographics
NPI:1336892744
Name:GOMEZ, GLEN (PTA)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:GLEN
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:3816 PETRA CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-7113
Mailing Address - Country:US
Mailing Address - Phone:331-253-8167
Mailing Address - Fax:
Practice Address - Street 1:605 EDWARD DR
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-6507
Practice Address - Country:US
Practice Address - Phone:331-808-1362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005645225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant