Healthcare Provider Details

I. General information

NPI: 1710188701
Provider Name (Legal Business Name): MISS DULCE RAFAELA GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 9TH ST
CRESCENT CITY CA
95531-3432
US

IV. Provider business mailing address

9650 ZELZAH AVE
NORTHRIDGE CA
91325-2003
US

V. Phone/Fax

Practice location:
  • Phone: 707-464-4349
  • Fax: 707-464-4572
Mailing address:
  • Phone: 818-993-9311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number96203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: