Provider Demographics
NPI:1083959845
Name:GOMEZ, LORI BETH (LMSW, LADAC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:BETH
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LMSW, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:PENASCO
Mailing Address - State:NM
Mailing Address - Zip Code:87553-0127
Mailing Address - Country:US
Mailing Address - Phone:575-587-2519
Mailing Address - Fax:
Practice Address - Street 1:PICURIS PUEBLO
Practice Address - Street 2:201 A PUEBLO VIEW RD.
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553
Practice Address - Country:US
Practice Address - Phone:575-587-2519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0134501101YA0400X
NMM-05573104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)