Provider Demographics
NPI:1588276265
Name:GOMEZ, MELLANY (MT-BC)
Entity type:Individual
Prefix:
First Name:MELLANY
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 GREENWICH ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06120-1107
Mailing Address - Country:US
Mailing Address - Phone:860-329-1357
Mailing Address - Fax:
Practice Address - Street 1:30 GREENWICH ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06120-1107
Practice Address - Country:US
Practice Address - Phone:860-329-1357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-23
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225A00000X
CT225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist