Provider Demographics
NPI:1922835875
Name:LOPEZ-GOMEZ, MYRIAM ELIS
Entity type:Individual
Prefix:
First Name:MYRIAM
Middle Name:ELIS
Last Name:LOPEZ-GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 UNIONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3238
Mailing Address - Country:US
Mailing Address - Phone:516-444-6519
Mailing Address - Fax:
Practice Address - Street 1:880 UNIONDALE AVE
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-3238
Practice Address - Country:US
Practice Address - Phone:516-444-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health