Healthcare Provider Details

I. General information

NPI: 1750788295
Provider Name (Legal Business Name): ANTOINETTE MARIA GOMEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2014
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18230 E SILVER CREEK AVE BLDG 392
BUCKLEY SFB CO
80011-9501
US

IV. Provider business mailing address

18230 E SILVER CREEK AVE BLDG 392
BUCKLEY AFB CO
80011-9501
US

V. Phone/Fax

Practice location:
  • Phone: 720-847-6451
  • Fax:
Mailing address:
  • Phone: 720-847-6451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACC.0007304
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT.0001713
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09923355
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: