Provider Demographics
NPI:1164144465
Name:GOMEZ, BRANDON RENE
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:RENE
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 1:1501 W CAMERON AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2724
Mailing Address - Country:US
Mailing Address - Phone:323-302-9997
Mailing Address - Fax:818-736-4189
Practice Address - Street 1:879 W 190TH ST STE 400
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4223
Practice Address - Country:US
Practice Address - Phone:323-302-9997
Practice Address - Fax:818-736-4189
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician