Healthcare Provider Details

I. General information

NPI: 1992587422
Provider Name (Legal Business Name): IVAN GOMEZ LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 W DOWNER PL STE 307308
AURORA IL
60506-5123
US

IV. Provider business mailing address

1013 LEGRANDE AVE
AURORA IL
60506-6381
US

V. Phone/Fax

Practice location:
  • Phone: 630-733-9108
  • Fax:
Mailing address:
  • Phone: 630-765-4147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178018438
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: