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Individual

MARISSA PAULETTE GOMEZ

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man

Contact information

Practice address
12200 MONTGOMERY BLVD NE APT D202, ALBUQUERQUE, NM 87111-4197
(575) 288-8402
Mailing address
12200 MONTGOMERY BLVD NE APT D202, ALBUQUERQUE, NM 87111-4197
(575) 288-8402

Taxonomy

Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
172A00000X
Driver
513575084
NM

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
3624309576
NM
Enumeration date
02/04/2019
Last updated
02/27/2019
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