Provider Demographics
NPI:1649567652
Name:GOMEZ, ELIZABETH R (RAS G1008291735)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:RAS G1008291735
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 W ASHLAN AVE
Mailing Address - Street 2:118
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-1749
Mailing Address - Country:US
Mailing Address - Phone:559-999-2353
Mailing Address - Fax:
Practice Address - Street 1:3636 N 1ST ST # 135 & 154
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6800
Practice Address - Country:US
Practice Address - Phone:559-225-1464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1008291735101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)