Provider Demographics
NPI:1255989505
Name:GOMEZ, LUZ ELENA (NLC)
Entity type:Individual
Prefix:
First Name:LUZ
Middle Name:ELENA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:NLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4779 WILDE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-1244
Mailing Address - Country:US
Mailing Address - Phone:719-482-0197
Mailing Address - Fax:
Practice Address - Street 1:125 N PARKSIDE DR STE 204
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-6159
Practice Address - Country:US
Practice Address - Phone:719-465-2582
Practice Address - Fax:719-465-2643
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0108775101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO161531082OtherUNITEDHEALTHCARE