Healthcare Provider Details

I. General information

NPI: 1194465344
Provider Name (Legal Business Name): BRENDA ESMERALDA GOMES LSSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 GROVE BND
SAN ANTONIO TX
78253-5752
US

IV. Provider business mailing address

903 GROVE BND
SAN ANTONIO TX
78253-5752
US

V. Phone/Fax

Practice location:
  • Phone: 480-650-8919
  • Fax:
Mailing address:
  • Phone: 480-650-8919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number72094
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: