Healthcare Provider Details

I. General information

NPI: 1801422084
Provider Name (Legal Business Name): STEPHANIE GOMEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE HURST LCSW

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date: 04/16/2023
Reactivation Date: 05/03/2023

III. Provider practice location address

122 SHADOW LAWN DR
BYRON GA
31008-3016
US

IV. Provider business mailing address

122 SHADOW LAWN DR
BYRON GA
31008-3016
US

V. Phone/Fax

Practice location:
  • Phone: 502-230-9633
  • Fax:
Mailing address:
  • Phone: 502-230-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number254693
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009985
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21403
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTLS.486.CP
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: