MEDICARE: MRS. LACY WATSON GOMOKE MS.,CCC-SLP

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	235Z00000X	Speech-Language Pathologist	2202004157	VA

General Provider Information

NPI Number	:	1639360530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LACY WATSON GOMOKE MS.,CCC-SLP

Provider Business Mailing Address
First Line	:	3620 CALVERTON WAY
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-4463
Country	:	US
Telephone Number	:	757-484-9320
Fax Number	:

Provider Business Practice Location Address
First Line	:	3620 CALVERTON WAY
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-4463
Country	:	US
Telephone Number	:	757-484-9320
Fax Number	:

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/06/2007

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