Provider Demographics
NPI:1073889994
Name:GOMELAURI, VAKHTANG (LCSW)
Entity type:Individual
Prefix:MR
First Name:VAKHTANG
Middle Name:
Last Name:GOMELAURI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 COURT ST STE 1009
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11242-1110
Mailing Address - Country:US
Mailing Address - Phone:347-699-8910
Mailing Address - Fax:267-378-9424
Practice Address - Street 1:26 COURT ST STE 1009
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11242-1110
Practice Address - Country:US
Practice Address - Phone:347-699-8910
Practice Address - Fax:267-378-9424
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085580104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY085580OtherTHE UNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPARTMENT