Provider Demographics
NPI:1710526835
Name:GOMEZ, MACEY MARIE
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:MARIE
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 1:1641 GEIS ST
Mailing Address - Street 2:
Mailing Address - City:DOS PALOS
Mailing Address - State:CA
Mailing Address - Zip Code:93620-2744
Mailing Address - Country:US
Mailing Address - Phone:559-974-3315
Mailing Address - Fax:
Practice Address - Street 1:3313 G ST STE B
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0992
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician