Healthcare Provider Details

I. General information

NPI: 1083959845
Provider Name (Legal Business Name): LORI BETH GOMEZ LMSW, LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 07/20/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PICURIS PUEBLO 201 A PUEBLO VIEW RD.
PENASCO NM
87553
US

IV. Provider business mailing address

PO BOX 127
PENASCO NM
87553-0127
US

V. Phone/Fax

Practice location:
  • Phone: 575-587-2519
  • Fax:
Mailing address:
  • Phone: 575-587-2519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0134501
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-05573
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: