Provider Demographics
NPI:1528737889
Name:GAMEZ, MARLON VINCENTE
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:VINCENTE
Last Name:GAMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14524 CORTINA DR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638
Mailing Address - Country:US
Mailing Address - Phone:562-447-3238
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143941106H00000X
CAR1443740921101YA0400X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist