Healthcare Provider Details

I. General information

NPI: 1790492940
Provider Name (Legal Business Name): ALISSA RAE GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date: 11/06/2023
Reactivation Date: 02/21/2024

III. Provider practice location address

2719 N AIR FRESNO DR
FRESNO CA
93727-1547
US

IV. Provider business mailing address

6051 N FRESNO ST STE 201
FRESNO CA
93710-5280
US

V. Phone/Fax

Practice location:
  • Phone: 559-351-3276
  • Fax:
Mailing address:
  • Phone: 559-248-8550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-IOVSKH
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number153835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: