Provider Demographics
NPI:1699071969
Name:GOMEZ, STEPHANIE MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
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 1:805 CONESTOGA TRL
Mailing Address - Street 2:
Mailing Address - City:RHOME
Mailing Address - State:TX
Mailing Address - Zip Code:76078-4216
Mailing Address - Country:US
Mailing Address - Phone:817-269-7060
Mailing Address - Fax:877-275-1630
Practice Address - Street 1:3345 WESTERN CENTER BLVD STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-1938
Practice Address - Country:US
Practice Address - Phone:817-269-7060
Practice Address - Fax:817-636-2704
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB119241OtherMEDICARE PTAN