Basic Information
Provider Information | |||||||||
NPI: | 1316121320 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMEZ | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | DANIEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029054541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014446779 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1011 VETERANS MEMORIAL PKWY | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | RI | ||||||||
PostalCode: | 029155061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014321000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2007 | ||||||||
LastUpdateDate: | 09/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1156 | OK | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TC0700X | TLMLP1139 | KS | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 37162 | TX | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC2200X | PS01997 | RI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
ID | Type | State | Issuer | Description | 1841281805 | 05 | KS |   | MEDICAID |