Provider Demographics
NPI:1558628271
Name:GOMEZ, JOSE MATEO (MA, LPC, CAADC, CCS)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:MATEO
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MA, LPC, CAADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30521 SCHOENHERR RD # 200A
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30521 SCHOENHERR RD # 200A
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3161
Practice Address - Country:US
Practice Address - Phone:586-275-7308
Practice Address - Fax:248-609-7472
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6401018930101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)