Provider Demographics
NPI:1417343104
Name:GOMBOS, JULIA
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:GOMBOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1305
Mailing Address - Street 2:
Mailing Address - City:OCCIDENTAL
Mailing Address - State:CA
Mailing Address - Zip Code:95465-1305
Mailing Address - Country:US
Mailing Address - Phone:415-250-9856
Mailing Address - Fax:
Practice Address - Street 1:1044 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1449
Practice Address - Country:US
Practice Address - Phone:415-250-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT22623106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist