Provider Demographics
NPI:1841709797
Name:GOMEZ, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 48TH ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-5311
Mailing Address - Country:US
Mailing Address - Phone:646-894-1157
Mailing Address - Fax:
Practice Address - Street 1:45-25 48 STREET
Practice Address - Street 2:APT 3C
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:646-894-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021922225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics