Healthcare Provider Details

I. General information

NPI: 1750409918
Provider Name (Legal Business Name): KATHERINE ANGELA MIELE GOMEZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST VC-4
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

34 BOGARDUS PL APT 7D
NEW YORK NY
10040-2340
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9099
  • Fax: 212-305-7400
Mailing address:
  • Phone: 917-837-7239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number013938
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: