Provider Demographics
NPI:1790492940
Name:GOMEZ, ALISSA RAE
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:RAE
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 1:615 S DEMAREE ST APT 31
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-1747
Mailing Address - Country:US
Mailing Address - Phone:559-351-3276
Mailing Address - Fax:
Practice Address - Street 1:450 KINGS COUNTY DR STE 104
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5785
Practice Address - Country:US
Practice Address - Phone:559-415-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2024-02-26
Deactivation Date:2023-11-06
Deactivation Code:
Reactivation Date:2024-02-21
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
390200000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program