Provider Demographics
NPI:1962523175
Name:GOMEZ, KENNETH W
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 MERRIMON AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28804-2405
Mailing Address - Country:US
Mailing Address - Phone:828-251-6091
Mailing Address - Fax:828-251-6911
Practice Address - Street 1:852 MERRIMON AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-2405
Practice Address - Country:US
Practice Address - Phone:828-251-6091
Practice Address - Fax:828-251-6911
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1436103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC03400OtherBLUE CROSS AND BLUE SHIELD
NC3403418Medicaid