Provider Demographics
NPI:1134978448
Name:GOMEZ, BENITO (RADT I)
Entity type:Individual
Prefix:
First Name:BENITO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:RADT I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2852 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:STEVINSON
Mailing Address - State:CA
Mailing Address - Zip Code:95374-9795
Mailing Address - Country:US
Mailing Address - Phone:209-226-5765
Mailing Address - Fax:
Practice Address - Street 1:1301 YOSEMITE PKWY
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-5203
Practice Address - Country:US
Practice Address - Phone:209-722-6335
Practice Address - Fax:209-722-6371
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1560460524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty