Healthcare Provider Details

I. General information

NPI: 1558417402
Provider Name (Legal Business Name): PATRICIA WOLF GOMOLA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 S MAIN ST
MIDDLETOWN CT
06457-4211
US

IV. Provider business mailing address

272 S MAIN ST
MIDDLETOWN CT
06457-4211
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-9586
  • Fax: 860-347-7626
Mailing address:
  • Phone: 860-347-9586
  • Fax: 860-347-7626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number002266
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: