Healthcare Provider Details

I. General information

NPI: 1316884778
Provider Name (Legal Business Name): MR. TIMOTHY J GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2026
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S STATE ST APT 104
ELGIN IL
60123-6444
US

IV. Provider business mailing address

PO BOX 213
ELGIN IL
60121-0213
US

V. Phone/Fax

Practice location:
  • Phone: 224-483-6603
  • Fax: 224-483-6603
Mailing address:
  • Phone: 224-483-6603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.022810
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: