Healthcare Provider Details

I. General information

NPI: 1548534050
Provider Name (Legal Business Name): BRENDA GOMEZ BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 E 84TH PL
MERRILLVILLE IN
46410-6451
US

IV. Provider business mailing address

8400 LOUISIANA ST
MERRILLVILLE IN
46410-6385
US

V. Phone/Fax

Practice location:
  • Phone: 219-794-2000
  • Fax: 219-794-2010
Mailing address:
  • Phone: 219-757-1928
  • Fax: 219-757-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: