Provider Demographics
NPI:1619263167
Name:GOMERINGER, MARY KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KELLY
Last Name:GOMERINGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E LAKEWOOD AVE
Mailing Address - Street 2:STE E
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-1700
Mailing Address - Country:US
Mailing Address - Phone:919-286-2146
Mailing Address - Fax:919-908-6787
Practice Address - Street 1:401 E LAKEWOOD AVE
Practice Address - Street 2:STE E
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1700
Practice Address - Country:US
Practice Address - Phone:919-286-2146
Practice Address - Fax:919-908-6787
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0079141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical