Provider Demographics
NPI:1669787800
Name:GOMEZ, INGRID E (APSW, SAC-IT)
Entity type:Individual
Prefix:MS
First Name:INGRID
Middle Name:E
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:APSW, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 N WEIL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3060
Mailing Address - Country:US
Mailing Address - Phone:414-962-1200
Mailing Address - Fax:414-962-2305
Practice Address - Street 1:2625 N WEIL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3060
Practice Address - Country:US
Practice Address - Phone:414-962-1200
Practice Address - Fax:414-962-2305
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15576-130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI127821-121OtherAPSW
WI15576-130OtherSAC-IT