Provider Demographics
NPI:1437821097
Name:GOMEZ, LISA ESTEFAN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ESTEFAN
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 54TH ST
Mailing Address - Street 2:
Mailing Address - City:FENNVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49408-8518
Mailing Address - Country:US
Mailing Address - Phone:616-312-9765
Mailing Address - Fax:
Practice Address - Street 1:2857 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5126
Practice Address - Country:US
Practice Address - Phone:718-235-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113299104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker