Provider Demographics
NPI:1912541541
Name:GOMEZ, LAURA
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
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 1:322 W SANDISON ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-2050
Mailing Address - Country:US
Mailing Address - Phone:310-977-8749
Mailing Address - Fax:
Practice Address - Street 1:18726 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3813
Practice Address - Country:US
Practice Address - Phone:310-856-0800
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-23-69622103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst