Basic Information
| Provider Information | |||||||||
| NPI: | 1841646619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | RAFAEL | ||||||||
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| Credential: | MFT INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1721 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232214134 | ||||||||
| FaxNumber: | 3232213231 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900313312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232214134 | ||||||||
| FaxNumber: | 3232213231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 113350 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | IMF91959 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 91959 | CA | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.