Provider Demographics
NPI:1689394363
Name:GOMEZ, HOLLY FOREMAN (MSW, LSWAIC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:FOREMAN
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MSW, LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6913 FRESCO DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-5065
Mailing Address - Country:US
Mailing Address - Phone:919-895-8294
Mailing Address - Fax:
Practice Address - Street 1:107 1ST ST NE
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597
Practice Address - Country:US
Practice Address - Phone:360-458-6124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA612132341041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool