Basic Information
| Provider Information | |||||||||
| NPI: | 1023234291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | EVANGELINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOMEZ | ||||||||
| OtherFirstName: | EVA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CADC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 03/27/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CADC G0605261426 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | ZZZ91892Z | 01 | CA | SANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN# | OTHER | FHC70042F | 01 | CA | SANTA CRUZ COUNTY CALIFORNIA MEDI-CAL GROUP PTAN# | OTHER | FHC70044F | 01 | CA | SANTA CRUZ COUNTY CALIFORNIA MEDI-CAL GROUP PTAN# | OTHER | G0605261426 | 01 | CA | CADC REGISTRATION | OTHER | ZZZ91891Z | 01 | CA | SANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN# | OTHER | ZZZ92069Z | 01 | CA | SANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN# | OTHER |