Provider Demographics
NPI:1891018180
Name:GOMEZ, GABRIELA TAMARA
Entity Type:Individual
Prefix:
First Name:GABRIELA
Middle Name:TAMARA
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 1:8253 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7671
Mailing Address - Country:US
Mailing Address - Phone:909-987-1997
Mailing Address - Fax:909-987-0993
Practice Address - Street 1:8253 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-987-1997
Practice Address - Fax:909-987-0993
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103831106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1946482Medicaid