Healthcare Provider Details

I. General information

NPI: 1225871445
Provider Name (Legal Business Name): DEIDRE GOMEZ LMSW, CSW INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2024
Last Update Date: 06/15/2024
Certification Date: 06/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5426 VEGAS DR
LAS VEGAS NV
89108-2403
US

IV. Provider business mailing address

5426 VEGAS DR
LAS VEGAS NV
89108-2403
US

V. Phone/Fax

Practice location:
  • Phone: 702-806-5268
  • Fax: 702-485-1107
Mailing address:
  • Phone: 702-806-5268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11489-M
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: