Provider Demographics
NPI:1770761058
Name:GOMEZ, MAYRA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:GOMEZ
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 1:600 W GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-4300
Mailing Address - Country:US
Mailing Address - Phone:626-804-7577
Mailing Address - Fax:
Practice Address - Street 1:11001 VALLEY MALL
Practice Address - Street 2:SUITE 300
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2620
Practice Address - Country:US
Practice Address - Phone:626-442-0710
Practice Address - Fax:626-442-8381
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN793OtherLA COUNTY DMH STAFF CODE