Provider Demographics
NPI:1407501562
Name:GOMEZ, MICAELA T (PHD)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:T
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4800
Mailing Address - Country:US
Mailing Address - Phone:209-620-0417
Mailing Address - Fax:
Practice Address - Street 1:1260 7TH ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4337
Practice Address - Country:US
Practice Address - Phone:209-826-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3142103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3142OtherBOARD OF BEHAVIORAL SCIENCES