Provider Demographics
NPI:1043877194
Name:GOMEZ, ALISSA JADE
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:JADE
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 1:5803 W CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2536
Mailing Address - Country:US
Mailing Address - Phone:702-901-5200
Mailing Address - Fax:
Practice Address - Street 1:5803 W CRAIG RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2536
Practice Address - Country:US
Practice Address - Phone:702-901-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1405392966106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician