MEDICARE: HANNAH ELISE GOMEZ BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-17-27809	IL

General Provider Information

NPI Number	:	1487163937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNAH ELISE GOMEZ BCBA

Provider Business Mailing Address
First Line	:	5 REVERE DR STE 120
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-8005
Country	:	US
Telephone Number	:	847-807-3717
Fax Number	:	847-348-3706

Provider Business Practice Location Address
First Line	:	2762 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2425
Country	:	US
Telephone Number	:	844-247-7222
Fax Number	:	847-348-3706

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2017
Last Update Date	:	01/10/2020

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