Provider Demographics
NPI:1487250304
Name:GOMEZ, SOPHIA NICOLE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:NICOLE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 S SUMMER ST APT 2
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-5948
Mailing Address - Country:US
Mailing Address - Phone:860-265-9634
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL ST STE 200
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5900
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health