=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154301810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAVIER H GOMEZ LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2006
-----------------------------------------------------
Last Update Date | 07/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6455 HILLER STE B-3
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-881-1300
-----------------------------------------------------
Fax | 915-755-1440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4748 HARCOURT
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79924-3047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-755-1000
-----------------------------------------------------
Fax | 915-755-1440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 08834
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------