Healthcare Provider Details

I. General information

NPI: 1518484724
Provider Name (Legal Business Name): LAURETTA GOMEZ LSWAIC, SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23211 NE STATE ROUTE 3 SUITE C
BELFAIR WA
98528
US

IV. Provider business mailing address

1402 SITTERLY PL E
PORT ORCHARD WA
98366-4528
US

V. Phone/Fax

Practice location:
  • Phone: 360-358-3039
  • Fax:
Mailing address:
  • Phone: 360-358-3039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWIA.SC.61603045
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP.CP.60782670
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: