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General NPI Number Information
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NPI Number | 1336400993
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Entity Type | Individual
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Provider Name | MARY THERESE GRAGEDA GOMEZ P.T.
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Gender | Female
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Dates
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Enumeration Date | 05/30/2012
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Last Update Date | 05/18/2023
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Provider Practice Location Address
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Address Line | 95-1057 AINAMAKUA DR UNIT F-11
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City | MILILANI
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State | HI
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Zip | 96789-6310
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Country | US
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Telephone | 808-597-1005
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Fax |
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Provider Business Mailing Address
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Address Line | 201 HAMAKUA DR # C102
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City | KAILUA
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State | HI
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Zip | 96734-3984
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Country | US
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Telephone | 808-597-1005
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 4917
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License Number State | HI
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