Provider Demographics
NPI:1609384064
Name:GOMEZ, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GOMEZ
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 1:4669 MURPHY CANYON RD STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4333
Mailing Address - Country:US
Mailing Address - Phone:858-569-0056
Mailing Address - Fax:858-569-4233
Practice Address - Street 1:4669 MURPHY CANYON RD STE 212
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4333
Practice Address - Country:US
Practice Address - Phone:858-569-0056
Practice Address - Fax:858-569-4233
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15-06626106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician