Basic Information
Provider Information | |||||||||
NPI: | 1396882874 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMEZ | ||||||||
FirstName: | SOCORRO | ||||||||
MiddleName: | MARIA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICENSED MFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOMEZ | ||||||||
OtherFirstName: | SOCORRO | ||||||||
OtherMiddleName: | MARIA | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MFC 45862 | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 933 AZURE CT | ||||||||
Address2: |   | ||||||||
City: | UPLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 917866408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9092107581 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17216 SLOVER AVE BLDG L | ||||||||
Address2: |   | ||||||||
City: | FONTANA | ||||||||
State: | CA | ||||||||
PostalCode: | 923377580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9098543420 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2007 | ||||||||
LastUpdateDate: | 04/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 45862 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.