Provider Demographics
NPI:1487125910
Name:GOMEZ, ROSANNA DIANE
Entity type:Individual
Prefix:
First Name:ROSANNA
Middle Name:DIANE
Last Name:GOMEZ
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:PO BOX 1185
Mailing Address - Street 2:
Mailing Address - City:CARNEGIE
Mailing Address - State:OK
Mailing Address - Zip Code:73015-1185
Mailing Address - Country:US
Mailing Address - Phone:580-919-8870
Mailing Address - Fax:
Practice Address - Street 1:722 TOWN EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:CARNEGIE
Practice Address - State:OK
Practice Address - Zip Code:73015-9012
Practice Address - Country:US
Practice Address - Phone:580-574-4183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10450101YM0800X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1487125910Medicaid