Provider Demographics
NPI:1679220453
Name:BLAKELY GOMEZ, EVALYN
Entity type:Individual
Prefix:
First Name:EVALYN
Middle Name:
Last Name:BLAKELY 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 1:25910 ACERO STE 160
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25910 ACERO STE 160
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2777
Practice Address - Country:US
Practice Address - Phone:877-564-8974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician