Healthcare Provider Details

I. General information

NPI: 1194024844
Provider Name (Legal Business Name): CARMEN T GOMEZ-JEFFREY MA, LPCC-ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARMEN TERESA GOMEZ

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE.0500338-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.0500338
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: