Provider Demographics
NPI:1518571413
Name:GOMEZ, COLE NICOLAS
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:NICOLAS
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 HASTINGS LN
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3324
Mailing Address - Country:US
Mailing Address - Phone:252-621-1366
Mailing Address - Fax:
Practice Address - Street 1:208 HASTINGS LN
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3324
Practice Address - Country:US
Practice Address - Phone:252-621-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401002431103K00000X, 103K00000X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist