Provider Demographics
NPI:1073252201
Name:GOMEZ DE SOBREVILLA, ELISA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIE
Last Name:GOMEZ DE SOBREVILLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6609 BLANCO RD STE 365
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6171
Mailing Address - Country:US
Mailing Address - Phone:210-705-1749
Mailing Address - Fax:210-610-5256
Practice Address - Street 1:6609 BLANCO RD STE 365
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6171
Practice Address - Country:US
Practice Address - Phone:210-705-1749
Practice Address - Fax:210-610-5256
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-04
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical