Provider Demographics
NPI:1215151196
Name:GOMEZ, LISSY MARIEL
Entity type:Individual
Prefix:MISS
First Name:LISSY
Middle Name:MARIEL
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 BOW ARROW DR
Mailing Address - Street 2:APT. 1071
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-4488
Mailing Address - Country:US
Mailing Address - Phone:214-331-0133
Mailing Address - Fax:
Practice Address - Street 1:1353 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1655
Practice Address - Country:US
Practice Address - Phone:214-331-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health