Provider Demographics
NPI:1801437918
Name:GOMEZ CABALLERO, OFELIA MARLENY (PPS)
Entity type:Individual
Prefix:
First Name:OFELIA
Middle Name:MARLENY
Last Name:GOMEZ CABALLERO
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 LIZZIE ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3062
Mailing Address - Country:US
Mailing Address - Phone:805-771-1841
Mailing Address - Fax:
Practice Address - Street 1:235 ATASCADERO RD
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1516
Practice Address - Country:US
Practice Address - Phone:805-771-1845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool