Provider Demographics
NPI:1528331451
Name:GOMEZ, CARLOS EMERY (LCSW)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:EMERY
Last Name:GOMEZ
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 1:294 E TABERNACLE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2936
Mailing Address - Country:US
Mailing Address - Phone:801-995-1788
Mailing Address - Fax:
Practice Address - Street 1:294 E TABERNACLE ST STE 100
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2936
Practice Address - Country:US
Practice Address - Phone:801-995-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
UT9681278-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1528331451Medicaid