Provider Demographics
NPI:1316954118
Name:GOMEZ, JOSE JAVIER (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:JAVIER
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COLVILLE ST
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155
Mailing Address - Country:US
Mailing Address - Phone:509-634-2642
Mailing Address - Fax:
Practice Address - Street 1:1 COLVILLE ST
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155
Practice Address - Country:US
Practice Address - Phone:509-634-2642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1980812Medicaid