Provider Demographics
NPI:1992587422
Name:GOMEZ, IVAN (LPC, NCC)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 LEGRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-6381
Mailing Address - Country:US
Mailing Address - Phone:630-765-4147
Mailing Address - Fax:
Practice Address - Street 1:31 W DOWNER PL STE 307308
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-5123
Practice Address - Country:US
Practice Address - Phone:630-733-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178018438101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional