Provider Demographics
NPI:1417022278
Name:GOMEZ, MARK DAVID (MED, LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 GATEWAY DR
Mailing Address - Street 2:STE. 290
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2646
Mailing Address - Country:US
Mailing Address - Phone:972-257-0449
Mailing Address - Fax:972-258-0449
Practice Address - Street 1:3021 GATEWAY DR
Practice Address - Street 2:STE. 290
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2646
Practice Address - Country:US
Practice Address - Phone:972-257-0449
Practice Address - Fax:972-258-0449
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional