Provider Demographics
NPI:1700369303
Name:GOMEZ, JOHNATHAN RAY (LSW)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:RAY
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 HAMLET ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2599
Mailing Address - Country:US
Mailing Address - Phone:614-294-8097
Mailing Address - Fax:
Practice Address - Street 1:1421 HAMLET ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2599
Practice Address - Country:US
Practice Address - Phone:614-294-8097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1802096104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker