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General NPI Number Information
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NPI Number | 1205481306
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Entity Type | Individual
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Provider Name | JUDITH GOMEZ LAC
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Gender | Female
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Dates
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Enumeration Date | 08/06/2019
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Last Update Date | 08/06/2019
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Provider Practice Location Address
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Address Line | 815 E CESAR CHAVEZ BLVD
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City | SAN LUIS
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State | AZ
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Zip | 85349
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Country | US
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Telephone | 928-627-3822
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Fax | 928-627-6666
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Provider Business Mailing Address
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Address Line | PO BOX 2017
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City | SAN LUIS
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State | AZ
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Zip | 85349-2017
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Country | US
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Telephone | 928-627-3822
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LAC-16498
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License Number State | AZ
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