Provider Demographics
NPI:1215220645
Name:WILLIAM GOMES
Entity Type:Organization
Organization Name:WILLIAM GOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTEUS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:203-756-8317
Mailing Address - Street 1:34 MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-1920
Mailing Address - Country:US
Mailing Address - Phone:203-756-8317
Mailing Address - Fax:203-756-8310
Practice Address - Street 1:34 MURRAY ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1920
Practice Address - Country:US
Practice Address - Phone:203-756-8317
Practice Address - Fax:203-756-8310
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY SERVICES OF GREATER WATERBURY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-18
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007396251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management