Provider Demographics
NPI:1699334623
Name:GOMEZ, MARISSA SALAS
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:SALAS
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 1:84329 REDONDO SUR
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-7321
Mailing Address - Country:US
Mailing Address - Phone:442-400-0980
Mailing Address - Fax:
Practice Address - Street 1:84329 REDONDO SUR
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-7321
Practice Address - Country:US
Practice Address - Phone:442-400-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty