Provider Demographics
NPI:1699908418
Name:GOMEZ, LEORA M
Entity type:Individual
Prefix:
First Name:LEORA
Middle Name:M
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEORA
Other - Middle Name:M
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3248 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6257
Mailing Address - Country:US
Mailing Address - Phone:309-347-5579
Mailing Address - Fax:309-347-4264
Practice Address - Street 1:3248 VANDEVER AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6257
Practice Address - Country:US
Practice Address - Phone:309-347-5579
Practice Address - Fax:309-347-4264
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor