Healthcare Provider Details

I. General information

NPI: 1184277949
Provider Name (Legal Business Name): NANCY JESSENIA GOMEZ LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W MAIN ST
SUN PRAIRIE WI
53590-1812
US

IV. Provider business mailing address

1500 W MAIN ST
SUN PRAIRIE WI
53590-1812
US

V. Phone/Fax

Practice location:
  • Phone: 608-453-7879
  • Fax: 608-453-7878
Mailing address:
  • Phone: 608-453-7879
  • Fax: 608-453-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number14233377-3902
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1405-124
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number206127
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: