Provider Demographics
NPI:1407340631
Name:GOMEZ, ANTHONY ROBERT JR (CADCI CI21600218)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:ROBERT
Last Name:GOMEZ
Suffix:JR
Gender:M
Credentials:CADCI CI21600218
Other - Prefix:
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Mailing Address - Street 1:1971 ESSEX CT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8057
Mailing Address - Country:US
Mailing Address - Phone:800-474-4848
Mailing Address - Fax:909-748-6424
Practice Address - Street 1:36442 WILDWOOD CANYON RD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-5274
Practice Address - Country:US
Practice Address - Phone:800-474-4848
Practice Address - Fax:909-748-6424
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CACI21600218106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician