Provider Demographics
NPI:1063781771
Name:GOMER, JULIE ANN (DBH)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:ANN
Last Name:GOMER
Suffix:
Gender:F
Credentials:DBH
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:MELIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13700 REIMER DRIVE N.
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311
Mailing Address - Country:US
Mailing Address - Phone:763-424-2474
Mailing Address - Fax:763-424-2711
Practice Address - Street 1:13700 REIMER DR N STE 220
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4548
Practice Address - Country:US
Practice Address - Phone:763-424-2474
Practice Address - Fax:763-424-2711
Is Sole Proprietor?:No
Enumeration Date:2011-12-26
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X
MNCC01538103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education