Provider Demographics
NPI:1770764334
Name:GOMORA, SUSANA
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:GOMORA
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 1:209 SW 4TH AVE STE 520
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1825
Mailing Address - Country:US
Mailing Address - Phone:503-988-5464
Mailing Address - Fax:503-988-4015
Practice Address - Street 1:209 SW 4TH AVE STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1825
Practice Address - Country:US
Practice Address - Phone:971-710-4424
Practice Address - Fax:503-988-4386
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW609391041C0700X
OR23-QMHP-R-2008101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical