Provider Demographics
NPI:1144343377
Name:GOMEZ, ROSALILIA (CDCI, BHCII)
Entity type:Individual
Prefix:MRS
First Name:ROSALILIA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:CDCI, BHCII
Other - Prefix:MRS
Other - First Name:ROSA
Other - Middle Name:LILLY
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17216 SLOVER AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-7580
Mailing Address - Country:US
Mailing Address - Phone:909-854-3420
Mailing Address - Fax:
Practice Address - Street 1:851 E WESTPOINT DR STE 310
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7183
Practice Address - Country:US
Practice Address - Phone:907-357-5400
Practice Address - Fax:907-357-5477
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)