Healthcare Provider Details

I. General information

NPI: 1821134024
Provider Name (Legal Business Name): MARTA LIZETTE GOMEZ MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 49TH STREET NORTH SUITE S-102
ST. PETERSBURG FL
33709
US

IV. Provider business mailing address

5800 49TH STREET NORTH SUITE S-102
ST. PETERSBURG FL
33709
US

V. Phone/Fax

Practice location:
  • Phone: 727-776-5502
  • Fax: 727-322-6143
Mailing address:
  • Phone: 727-776-5502
  • Fax: 727-894-2593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8027
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2101
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: