Basic Information
| Provider Information | |||||||||
| NPI: | 1073684536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | SUMMER | ||||||||
| MiddleName: | DAVIDSON | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 S ATLANTIC BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900401200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233189960 | ||||||||
| FaxNumber: | 3237803211 | ||||||||
| Practice Location | |||||||||
| Address1: | 5628 E SLAUSON AVE | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900402922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185881583 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 25416 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | #95-2633765 | 01 | CA | MEDI-CAL | OTHER |