Provider Demographics
NPI:1508467200
Name:GOMEZ, MONIQUE M (LMSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:M
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3923 S WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5761
Mailing Address - Country:US
Mailing Address - Phone:480-331-5227
Mailing Address - Fax:
Practice Address - Street 1:9030 S MCCLINTOCK DR STE 105
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-4553
Practice Address - Country:US
Practice Address - Phone:480-427-7883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-16886101YM0800X
AZMT-14892225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ14892OtherLICENSED MASSAGE THERAPIST