Provider Demographics
NPI:1659996494
Name:GOMEZ TLACOXOLAL, JOSE MANUEL (ACSW)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:GOMEZ TLACOXOLAL
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 MONTAGUE EXPY APT 423
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-8867
Mailing Address - Country:US
Mailing Address - Phone:831-214-6289
Mailing Address - Fax:
Practice Address - Street 1:510 SAND HILL RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2001
Practice Address - Country:US
Practice Address - Phone:650-470-6004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97149104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker