Provider Demographics
NPI:1790492940
Name:GOMEZ, ALISSA RAE
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:RAE
Last Name:GOMEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 N FRESNO ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5280
Mailing Address - Country:US
Mailing Address - Phone:559-248-8550
Mailing Address - Fax:
Practice Address - Street 1:6051 N FRESNO ST STE 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5280
Practice Address - Country:US
Practice Address - Phone:559-248-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2025-03-17
Deactivation Date:2023-11-06
Deactivation Code:
Reactivation Date:2024-02-21
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X, 106H00000X
CAMPSS-IOVSKH175T00000X
CA153835106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program