Provider Demographics
NPI:1104554401
Name:GOMEZ, MIRIAM GUADALUPE
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:GUADALUPE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 W LANCASTER BLVD UNIT 419
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93584-7016
Mailing Address - Country:US
Mailing Address - Phone:661-450-5257
Mailing Address - Fax:
Practice Address - Street 1:45111 FERN AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2301
Practice Address - Country:US
Practice Address - Phone:661-949-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-13
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1200101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program