Provider Demographics
NPI:1700532942
Name:GOMEZ, DOUGLAS (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 MANZANITA ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-4612
Mailing Address - Country:US
Mailing Address - Phone:714-981-5076
Mailing Address - Fax:
Practice Address - Street 1:91150 N COBURG INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9512
Practice Address - Country:US
Practice Address - Phone:541-284-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3506103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling