Provider Demographics
NPI:1740540848
Name:GOMEZTAGLE, EMILY R (MS-SLP-CCC)
Entity type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:R
Last Name:GOMEZTAGLE
Suffix:
Gender:F
Credentials:MS-SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2348 N LISTER AVE
Mailing Address - Street 2:207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2994
Mailing Address - Country:US
Mailing Address - Phone:219-308-9477
Mailing Address - Fax:
Practice Address - Street 1:5130 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4332
Practice Address - Country:US
Practice Address - Phone:219-308-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL146011739235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program