Basic Information
| Provider Information | |||||||||
| NPI: | 1144343377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | ROSALILIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CDCI, BHCII | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOMEZ | ||||||||
| OtherFirstName: | ROSA | ||||||||
| OtherMiddleName: | LILLY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17216 SLOVER AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923377580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098543420 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 851 E WESTPOINT DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073575400 | ||||||||
| FaxNumber: | 9073575477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | AK | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.