Basic Information
| Provider Information | |||||||||
| NPI: | 1457650434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | GRACIELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A., B.C.B.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12200 FORD RD | ||||||||
| Address2: | SUITE 189 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752347244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889222843 | ||||||||
| FaxNumber: | 3103243134 | ||||||||
| Practice Location | |||||||||
| Address1: | 12200 FORD RD | ||||||||
| Address2: | SUITE 189 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752347244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889222843 | ||||||||
| FaxNumber: | 3103243134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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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 | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.