Provider Demographics
NPI:1356023170
Name:GOMEZ HERNANDEZ, LAISHA MICHELLE
Entity type:Individual
Prefix:
First Name:LAISHA
Middle Name:MICHELLE
Last Name:GOMEZ HERNANDEZ
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 1:29106 MONTEREY CT
Mailing Address - Street 2:
Mailing Address - City:SANTA NELLA
Mailing Address - State:CA
Mailing Address - Zip Code:95322-9639
Mailing Address - Country:US
Mailing Address - Phone:209-710-7696
Mailing Address - Fax:209-710-7696
Practice Address - Street 1:29106 MONTEREY CT
Practice Address - Street 2:
Practice Address - City:SANTA NELLA
Practice Address - State:CA
Practice Address - Zip Code:95322-9639
Practice Address - Country:US
Practice Address - Phone:209-710-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician