Healthcare Provider Details

I. General information

NPI: 1699393140
Provider Name (Legal Business Name): YESENIA GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S POPLAR ST
SANTA ANA CA
92704-4321
US

IV. Provider business mailing address

1801 S POPLAR ST
SANTA ANA CA
92704-4321
US

V. Phone/Fax

Practice location:
  • Phone: 657-554-6619
  • Fax:
Mailing address:
  • Phone: 657-554-6619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW95574
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number95574
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: