Provider Demographics
NPI:1053539791
Name:GOMEZ, LAURA (COTA L)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:COTA L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 DONA ANA RD APT H
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-7391
Mailing Address - Country:US
Mailing Address - Phone:505-649-7699
Mailing Address - Fax:
Practice Address - Street 1:301 PERKINS DR STE B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3248
Practice Address - Country:US
Practice Address - Phone:505-523-7243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1324224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant