Provider Demographics
NPI:1992201669
Name:GOMEZ, NICHOLAS RAYMOND
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RAYMOND
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4067 W 3RD ST APT 404
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-5900
Mailing Address - Country:US
Mailing Address - Phone:626-221-0477
Mailing Address - Fax:
Practice Address - Street 1:177 E COLORADO BLVD STE 2082
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1986
Practice Address - Country:US
Practice Address - Phone:844-669-7827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-20-115416106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician