Provider Demographics
NPI:1255847034
Name:GOMEZ, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
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 1:1510 N LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93728-1100
Mailing Address - Country:US
Mailing Address - Phone:559-457-6860
Mailing Address - Fax:559-467-6859
Practice Address - Street 1:1510 N LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-1100
Practice Address - Country:US
Practice Address - Phone:559-457-6860
Practice Address - Fax:559-457-6859
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146464106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health