Provider Demographics
NPI:1346892874
Name:GOMEZ, KEVIN IBARRA
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:IBARRA
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26137 LA PAZ RD STE 230
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5337
Mailing Address - Country:US
Mailing Address - Phone:949-595-8610
Mailing Address - Fax:949-595-0296
Practice Address - Street 1:26137 LA PAZ RD STE 230
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5337
Practice Address - Country:US
Practice Address - Phone:949-595-8610
Practice Address - Fax:949-595-0296
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140795106H00000X
CA113011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist