Healthcare Provider Details

I. General information

NPI: 1891169033
Provider Name (Legal Business Name): MARICELA GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2015
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W ALLUVIAL AVE STE 108
FRESNO CA
93711-5857
US

IV. Provider business mailing address

6181 W CONCORDIA DR
FRESNO CA
93722-2666
US

V. Phone/Fax

Practice location:
  • Phone: 559-795-5990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPCCI2191
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC12320
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF87833
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC123206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: