Provider Demographics
NPI:1154764645
Name:GONGORA, LUIS ALBERTO
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALBERTO
Last Name:GONGORA
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 1:537 E ALLEGHENY AVE
Mailing Address - Street 2:APT/SUITE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-2328
Mailing Address - Country:US
Mailing Address - Phone:215-291-9500
Mailing Address - Fax:
Practice Address - Street 1:537 E ALLEGHENY AVE
Practice Address - Street 2:APT/SUITE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-2328
Practice Address - Country:US
Practice Address - Phone:215-291-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health