Provider Demographics
NPI:1225479736
Name:GOMEZ, MARLENE GUTIERREZ (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:GUTIERREZ
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10925 PALMS BLVD APT 30
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6169
Mailing Address - Country:US
Mailing Address - Phone:323-599-7219
Mailing Address - Fax:
Practice Address - Street 1:4700 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6082
Practice Address - Country:US
Practice Address - Phone:323-783-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA98989106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program