Provider Demographics
NPI:1396882874
Name:GOMEZ, SOCORRO MARIA (LICENSED MFT)
Entity type:Individual
Prefix:MS
First Name:SOCORRO
Middle Name:MARIA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LICENSED MFT
Other - Prefix:MS
Other - First Name:SOCORRO
Other - Middle Name:MARIA
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFC 45862
Mailing Address - Street 1:933 AZURE CT
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6408
Mailing Address - Country:US
Mailing Address - Phone:909-210-7581
Mailing Address - Fax:
Practice Address - Street 1:17216 SLOVER AVE BLDG L
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7580
Practice Address - Country:US
Practice Address - Phone:909-854-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 45862106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist