Healthcare Provider Details

I. General information

NPI: 1487931408
Provider Name (Legal Business Name): LUIS ALFONSO GOMEZ JR. LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JEROME AVE FEGS BRONX PROS
BRONX NY
10467-1052
US

IV. Provider business mailing address

53 VERMILYEA AVE 4D
NEW YORK NY
10034-4443
US

V. Phone/Fax

Practice location:
  • Phone: 718-881-7600
  • Fax: 718-654-1465
Mailing address:
  • Phone: 646-626-2545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number084983-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: