Healthcare Provider Details

I. General information

NPI: 1902489040
Provider Name (Legal Business Name): MARISSA D RODRIGUEZ GOMES LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 LAUREL AVE
IRVINGTON NJ
07111-1331
US

IV. Provider business mailing address

192 LAUREL AVE
IRVINGTON NJ
07111-1331
US

V. Phone/Fax

Practice location:
  • Phone: 559-903-1953
  • Fax:
Mailing address:
  • Phone: 559-903-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberF5340450
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL07393900
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number01724051
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number716767053
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1933343251
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number126020
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: