Healthcare Provider Details

I. General information

NPI: 1528331451
Provider Name (Legal Business Name): CARLOS EMERY GOMEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 E TABERNACLE ST STE 100
ST GEORGE UT
84770-2936
US

IV. Provider business mailing address

294 E TABERNACLE ST STE 100
ST GEORGE UT
84770-2936
US

V. Phone/Fax

Practice location:
  • Phone: 801-995-1788
  • Fax:
Mailing address:
  • Phone: 801-995-1788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9681278-3501
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1528331451
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: