Provider Demographics
NPI:1265189815
Name:GOMEZ, SHANNA (LMSW)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PATCHOGUE AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1627
Mailing Address - Country:US
Mailing Address - Phone:631-741-3786
Mailing Address - Fax:
Practice Address - Street 1:131 PATCHOGUE AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1627
Practice Address - Country:US
Practice Address - Phone:631-741-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081294104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker