Basic Information
| Provider Information | |||||||||
| NPI: | 1083168884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910102686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2016 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 85454 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.