MEDICARE: VANESSA ALEXANDRA GOMEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1104769686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA ALEXANDRA GOMEZ

Provider Business Mailing Address
First Line	:	9225 HALLMARK AVE S
Second Line	:
City	:	COTTAGE GROVE
State	:	MN
Zip	:	55016-3851
Country	:	US
Telephone Number	:	651-253-1404
Fax Number	:

Provider Business Practice Location Address
First Line	:	4130 BLACKHAWK RD STE 136-146
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-1700
Country	:	US
Telephone Number	:	651-515-1415
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2026
Last Update Date	:	04/10/2026

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Directions to “ VANESSA ALEXANDRA GOMEZ ” Practice Location

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