Provider Demographics
NPI:1821824863
Name:GOMEZ, DANIELLE JANE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:JANE
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 1:24701 RAYMOND WAY SPC 39
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4726
Mailing Address - Country:US
Mailing Address - Phone:949-434-7214
Mailing Address - Fax:
Practice Address - Street 1:24701 RAYMOND WAY SPC 39
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4726
Practice Address - Country:US
Practice Address - Phone:949-434-7214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician