Provider Demographics
NPI:1649089640
Name:GOMEZ-VASQUEZ, CARLA STACY
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:STACY
Last Name:GOMEZ-VASQUEZ
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 1:5108 MIRIAM ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2323
Mailing Address - Country:US
Mailing Address - Phone:626-660-9561
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE BLDG A10
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:626-349-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician