Healthcare Provider Details

I. General information

NPI: 1265634661
Provider Name (Legal Business Name): JOSE LUIS GOMEZ M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 PIERRE RD
WALNUT CA
91789-2534
US

IV. Provider business mailing address

341 PIERRE RD
WALNUT CA
91789-2534
US

V. Phone/Fax

Practice location:
  • Phone: 909-910-8458
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFT I 53711
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53711
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: