Healthcare Provider Details

I. General information

NPI: 1720642481
Provider Name (Legal Business Name): GIOVANNA RIVANO GOMEZ PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MICHIGAN AVE STE 223
CHICAGO IL
60601-7591
US

IV. Provider business mailing address

155 N MICHIGAN AVE STE 223
CHICAGO IL
60601-7591
US

V. Phone/Fax

Practice location:
  • Phone: 954-383-5643
  • Fax:
Mailing address:
  • Phone: 312-978-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071009248
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number071009248
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: