Provider Demographics
NPI:1356965917
Name:GOMBERG, GREGORY J
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:GOMBERG
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 1:515 E MAGNOLIA BLVD APT M
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-1933
Mailing Address - Country:US
Mailing Address - Phone:818-636-8687
Mailing Address - Fax:
Practice Address - Street 1:13101 W WASHINGTON BLVD STE 238
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5173
Practice Address - Country:US
Practice Address - Phone:310-853-8025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXED905998953OtherBLUE SHIELD CALIFORNIA