Provider Demographics
NPI:1083450142
Name:GOMEZ, MARCELINO PATIU (RBT)
Entity type:Individual
Prefix:
First Name:MARCELINO
Middle Name:PATIU
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 SUMMIT RDG
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-4103
Mailing Address - Country:US
Mailing Address - Phone:951-314-4021
Mailing Address - Fax:
Practice Address - Street 1:1901 CARNEGIE AVE STE 1C
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5504
Practice Address - Country:US
Practice Address - Phone:714-848-8319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician