Provider Demographics
NPI:1053738088
Name:GOMEZ, MATEO J
Entity type:Individual
Prefix:
First Name:MATEO
Middle Name:J
Last Name:GOMEZ
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 1:13122 APRIL DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-0902
Mailing Address - Country:US
Mailing Address - Phone:404-542-4605
Mailing Address - Fax:
Practice Address - Street 1:3208 ROSEMEAD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2830
Practice Address - Country:US
Practice Address - Phone:626-227-7014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113192106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist