Provider Demographics
NPI:1912412651
Name:GOMEZ, LEAH J
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:J
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:J
Other - Last Name:ONDROVICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1302 BRAMBLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-7721
Mailing Address - Country:US
Mailing Address - Phone:517-673-1877
Mailing Address - Fax:
Practice Address - Street 1:785 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1467
Practice Address - Country:US
Practice Address - Phone:517-673-1877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010007302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer