Provider Demographics
NPI:1114285772
Name:GOMERSALL, TIM (LEP)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:GOMERSALL
Suffix:
Gender:M
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6131
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6131
Mailing Address - Country:US
Mailing Address - Phone:707-407-7475
Mailing Address - Fax:707-441-1913
Practice Address - Street 1:525 2ND ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-5107
Practice Address - Country:US
Practice Address - Phone:707-407-7475
Practice Address - Fax:707-441-1913
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP 2754103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool