Provider Demographics
NPI:1922245174
Name:GOMEZ-FALCON, MARIAH R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIAH
Middle Name:R
Last Name:GOMEZ-FALCON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 SOUTH LAKE STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502
Mailing Address - Country:US
Mailing Address - Phone:818-848-5653
Mailing Address - Fax:
Practice Address - Street 1:905 SOUTH LAKE STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502
Practice Address - Country:US
Practice Address - Phone:818-848-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14147103TC0700X
FL0005280103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical