Provider Demographics
NPI:1780102434
Name:HENRIQUEZ-GOMEZ, RACHELLE HILDA MARIA (MA, LMFT 129286)
Entity type:Individual
Prefix:MRS
First Name:RACHELLE
Middle Name:HILDA MARIA
Last Name:HENRIQUEZ-GOMEZ
Suffix:
Gender:F
Credentials:MA, LMFT 129286
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1763
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-1439
Mailing Address - Country:US
Mailing Address - Phone:909-566-2344
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1763
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-1439
Practice Address - Country:US
Practice Address - Phone:909-566-2344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129286106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA6758Medicaid
CA7420Medicaid