Provider Demographics
NPI:1023234291
Name:GOMEZ, EVANGELINA (CADC)
Entity type:Individual
Prefix:MS
First Name:EVANGELINA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:831-454-4663
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACADC G0605261426101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherSANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN#
CAFHC70042FOtherSANTA CRUZ COUNTY CALIFORNIA MEDI-CAL GROUP PTAN#
CAFHC70044FOtherSANTA CRUZ COUNTY CALIFORNIA MEDI-CAL GROUP PTAN#
CAG0605261426OtherCADC REGISTRATION
CAZZZ91891ZOtherSANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN#
CAZZZ92069ZOtherSANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN#