Provider Demographics
NPI:1932364098
Name:GOMEZ, ROSA ELIA (DSW)
Entity Type:Individual
Prefix:DR
First Name:ROSA
Middle Name:ELIA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:DSW
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 9104
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-2304
Mailing Address - Country:US
Mailing Address - Phone:909-936-4599
Mailing Address - Fax:
Practice Address - Street 1:11801 PIERCE ST STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-4400
Practice Address - Country:US
Practice Address - Phone:909-369-4599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 16600101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health