Provider Demographics
NPI:1417584483
Name:GOMEZ, GINA (RADT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:
Credentials:RADT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14371 EL CONTENTO AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-0502
Mailing Address - Country:US
Mailing Address - Phone:909-855-2556
Mailing Address - Fax:
Practice Address - Street 1:812 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-2714
Practice Address - Country:US
Practice Address - Phone:909-395-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1379750320101YA0400X
CARH0016470225101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARH0015020425OtherRADT NUMBER CHANGE