Provider Demographics
NPI:1326289828
Name:GOMEZ, NELSON JR (PHD)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:GOMEZ
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 RANCHO CAMINO DR
Mailing Address - Street 2:STE 102
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-7008
Mailing Address - Country:US
Mailing Address - Phone:909-865-8500
Mailing Address - Fax:909-865-8552
Practice Address - Street 1:12 RANCHO CAMINO DR
Practice Address - Street 2:STE 102
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-7008
Practice Address - Country:US
Practice Address - Phone:909-865-8500
Practice Address - Fax:909-865-8552
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid
PSY27761OtherLICENSE NUMBER
CA7068Medicaid