Healthcare Provider Details

I. General information

NPI: 1134558661
Provider Name (Legal Business Name): REBECCA POOLE GOMEZ PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 420
MARIETTA GA
30060
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-6760
  • Fax: 770-794-8034
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003721
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: