Provider Demographics
NPI:1801507405
Name:GOMEZ, LARISSA GONSALEZ (LCSW)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:GONSALEZ
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11005 QUARRY OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-4440
Mailing Address - Country:US
Mailing Address - Phone:151-256-7967
Mailing Address - Fax:
Practice Address - Street 1:10824 E CRYSTAL FALLS PKWY STE 401
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-4301
Practice Address - Country:US
Practice Address - Phone:512-567-9679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX402301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical