Provider Demographics
NPI:1194465344
Name:GOMES, BRENDA ESMERALDA (LSSP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ESMERALDA
Last Name:GOMES
Suffix:
Gender:F
Credentials:LSSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 GROVE BND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5752
Mailing Address - Country:US
Mailing Address - Phone:480-650-8919
Mailing Address - Fax:
Practice Address - Street 1:903 GROVE BND
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-5752
Practice Address - Country:US
Practice Address - Phone:480-650-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72094103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool