Provider Demographics
NPI:1154051993
Name:GOMEZ, SARAH NICOLE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:NICOLE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:NICOLE
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5519 AVINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3190 ROCHESTER RD STE 105
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5464
Practice Address - Country:US
Practice Address - Phone:248-961-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI6451022404101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health