Provider Demographics
NPI:1437557709
Name:GOMEZ, FERNANDO (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 MCNUTT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9685
Mailing Address - Country:US
Mailing Address - Phone:575-882-5100
Mailing Address - Fax:575-882-1151
Practice Address - Street 1:5305 MCNUTT RD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9685
Practice Address - Country:US
Practice Address - Phone:575-882-5100
Practice Address - Fax:575-882-1151
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT0170901101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64153274Medicaid