Basic Information
| Provider Information | |||||||||
| NPI: | 1831696368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1485 SARATOGA AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951294965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779910009 | ||||||||
| FaxNumber: | 8772079553 | ||||||||
| Practice Location | |||||||||
| Address1: | 2326 OAK FLAT RD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951311929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6692526423 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-19-36579 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.