Provider Demographics
NPI:1447868385
Name:GOMEZ-GLILIAM, DAMARIS
Entity type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:GOMEZ-GLILIAM
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 1:7701 HIGWAY 51 NORTH
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:901-653-5091
Mailing Address - Fax:
Practice Address - Street 1:7921 CHESTERFIELD DR S
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6202
Practice Address - Country:US
Practice Address - Phone:901-563-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker