=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437821097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA ESTEFAN GOMEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2021
-----------------------------------------------------
Last Update Date | 10/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2857 LINDEN BLVD
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11208-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-235-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2312 54TH ST
-----------------------------------------------------
City | FENNVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49408-8518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-312-9765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 113299
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------