Provider Demographics
NPI:1578326161
Name:GOMEZ, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:22337 E VIA DEL PALO
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-3225
Mailing Address - Country:US
Mailing Address - Phone:858-226-6703
Mailing Address - Fax:
Practice Address - Street 1:22337 E VIA DEL PALO
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-3225
Practice Address - Country:US
Practice Address - Phone:858-226-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician