Provider Demographics
NPI:1992208854
Name:GOMEZ, PRISCILLA MARIE
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:MARIE
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 1:1140 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93905-1406
Mailing Address - Country:US
Mailing Address - Phone:831-676-6473
Mailing Address - Fax:
Practice Address - Street 1:1123 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3681
Practice Address - Country:US
Practice Address - Phone:888-512-2695
Practice Address - Fax:775-348-7631
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician