Provider Demographics
NPI:1891844486
Name:GOMES, KATHLEEN MARY (MS, CAS)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARY
Last Name:GOMES
Suffix:
Gender:F
Credentials:MS, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 STONE BALLAST WAY
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469
Mailing Address - Country:US
Mailing Address - Phone:910-754-3782
Mailing Address - Fax:
Practice Address - Street 1:120 COASTAL HORIZONS DR
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-6094
Practice Address - Country:US
Practice Address - Phone:910-754-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC349101YA0400X
NCS3928101YM0800X
NC930106H00000X
CT000227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist