Healthcare Provider Details

I. General information

NPI: 1790676245
Provider Name (Legal Business Name): LUPITA GOMEZ-HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 ADELINE ST
BERKELEY CA
94703-2407
US

IV. Provider business mailing address

17427 VIA MELINA
SAN LORENZO CA
94580-2644
US

V. Phone/Fax

Practice location:
  • Phone: 510-601-0203
  • Fax:
Mailing address:
  • Phone: 510-461-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: