Provider Demographics
NPI:1376002824
Name:GOMEZ, MARIA ISABEL (NCC, LAC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ISABEL
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:NCC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4630
Mailing Address - Country:US
Mailing Address - Phone:732-397-6418
Mailing Address - Fax:
Practice Address - Street 1:187 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-4140
Practice Address - Country:US
Practice Address - Phone:732-410-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00452400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health