Healthcare Provider Details

I. General information

NPI: 1275663205
Provider Name (Legal Business Name): LORI LYNN BREEDEN-GOMEZ M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 POINTE DR SUITE 305
BREA CA
92821-3651
US

IV. Provider business mailing address

3 POINTE DR SUITE 305
BREA CA
92821-3651
US

V. Phone/Fax

Practice location:
  • Phone: 714-613-2591
  • Fax: 714-256-0913
Mailing address:
  • Phone: 714-613-2591
  • Fax: 714-256-0913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC114
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC39712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: