Provider Demographics
NPI:1003244310
Name:GOMEZ, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 CHANATE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-1708
Mailing Address - Country:US
Mailing Address - Phone:707-565-4970
Mailing Address - Fax:
Practice Address - Street 1:7458 SANTA BARBARA DR
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-3840
Practice Address - Country:US
Practice Address - Phone:707-565-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33237167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician