Provider Demographics
NPI:1902115439
Name:GOMEZ, RAFAEL AMAYA
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:AMAYA
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RAFAEL
Other - Middle Name:AMAYA
Other - Last Name:ORTIZ-GOMEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COADC
Mailing Address - Street 1:4660 VIEWRIDGE AVE STE 100A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1638
Mailing Address - Country:US
Mailing Address - Phone:619-937-1430
Mailing Address - Fax:
Practice Address - Street 1:4660 VIEWRIDGE AVE STE 100A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1638
Practice Address - Country:US
Practice Address - Phone:619-937-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
CA112579III101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8544Medicaid