Provider Demographics
NPI:1235942962
Name:GOMEZ GODINEZ, LUIS FERNANDO
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:GOMEZ GODINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ALLEY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-4405
Mailing Address - Country:US
Mailing Address - Phone:617-240-9506
Mailing Address - Fax:
Practice Address - Street 1:110 BOSTON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-1402
Practice Address - Country:US
Practice Address - Phone:781-825-3986
Practice Address - Fax:781-595-1081
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS62532334101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty