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General NPI Number Information
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NPI Number | 1114285772
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Entity Type | Individual
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Provider Name | TIM GOMERSALL L.E.P.
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Gender | Male
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Dates
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Enumeration Date | 05/01/2012
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Last Update Date | 05/01/2012
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Provider Practice Location Address
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Address Line | 525 2ND ST
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City | EUREKA
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State | CA
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Zip | 95501-5107
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Country | US
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Telephone | 707-407-7475
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Fax | 707-441-1913
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Provider Business Mailing Address
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Address Line | PO BOX 6131
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City | EUREKA
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State | CA
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Zip | 95502-6131
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Country | US
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Telephone | 707-407-7475
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Fax | 707-441-1913
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | LEP 2754
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License Number State | CA
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