Provider Demographics
NPI:1578341475
Name:BORBA GOMEZ, IVANA ELISA (LAMFT)
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:ELISA
Last Name:BORBA GOMEZ
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2588 S 1000 W
Mailing Address - Street 2:
Mailing Address - City:NIBLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6545
Mailing Address - Country:US
Mailing Address - Phone:425-615-0860
Mailing Address - Fax:
Practice Address - Street 1:160 NW GILMAN BLVD STE 327
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2550
Practice Address - Country:US
Practice Address - Phone:425-615-0860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13575455-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist