Healthcare Provider Details

I. General information

NPI: 1508669961
Provider Name (Legal Business Name): VANESSA GOMEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N GREENLEAF ST STE 120
GURNEE IL
60031-3334
US

IV. Provider business mailing address

1104 PALMER PL
WAUKEGAN IL
60085-2050
US

V. Phone/Fax

Practice location:
  • Phone: 224-285-0728
  • Fax:
Mailing address:
  • Phone: 224-619-9173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.029010
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: