Basic Information
| Provider Information | |||||||||
| NPI: | 1891844486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMES | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1919 STONE BALLAST WAY | ||||||||
| Address2: | |||||||||
| City: | OCEAN ISLE BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107543782 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 COASTAL HORIZONS DR | ||||||||
| Address2: | |||||||||
| City: | SHALLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284706094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107544515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 349 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | S3928 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 930 | NC | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 000227 | CT | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.