Provider Demographics
NPI:1083168884
Name:GOMEZ, STEPHANIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
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 1:1002 FINEGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-1316
Mailing Address - Country:US
Mailing Address - Phone:626-803-2466
Mailing Address - Fax:
Practice Address - Street 1:1002 FINEGROVE AVE
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-1316
Practice Address - Country:US
Practice Address - Phone:626-803-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85454101YM0800X
390200000X
CA1230821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program