Provider Demographics
NPI:1164695615
Name:GOMEZ, STEPHENIE MARIE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHENIE
Middle Name:MARIE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:VENTURINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:9606 TIERRA GRANDE SUITE 107
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126
Mailing Address - Country:US
Mailing Address - Phone:858-695-9415
Mailing Address - Fax:858-695-9412
Practice Address - Street 1:9606 TIERRA GRANDE SUITE 107
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126
Practice Address - Country:US
Practice Address - Phone:858-695-9415
Practice Address - Fax:858-695-9412
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP14412235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist