Provider Demographics
NPI:1770816183
Name:GOMEZ, KERI NICOLE
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:NICOLE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:NICOLE
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17800 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1221
Mailing Address - Country:US
Mailing Address - Phone:760-242-6336
Mailing Address - Fax:760-242-5363
Practice Address - Street 1:17800 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1221
Practice Address - Country:US
Practice Address - Phone:760-242-6336
Practice Address - Fax:760-242-5363
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS294211041C0700X
CAASW 204541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical