Provider Demographics
NPI:1306636428
Name:GOMEZ, MIRANDA NICHOLE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICHOLE
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 1:8440 KIRKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4054
Mailing Address - Country:US
Mailing Address - Phone:909-565-0229
Mailing Address - Fax:
Practice Address - Street 1:8440 KIRKWOOD AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4054
Practice Address - Country:US
Practice Address - Phone:909-565-0229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty