Healthcare Provider Details

I. General information

NPI: 1396043329
Provider Name (Legal Business Name): RODOLFO MARTIN GOMEZ LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W SANTA ANA BLVD STE 600
SANTA ANA CA
92701-4552
US

IV. Provider business mailing address

PO BOX 63231
IRVINE CA
92602-6107
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 714-943-6498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT53751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: