Basic Information
| Provider Information | |||||||||
| NPI: | 1124217062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAVRIEL | ||||||||
| FirstName: | MARINA | ||||||||
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| Credential: | MH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1539 S SHENANDOAH ST | ||||||||
| Address2: | APT #303 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900354477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188041205 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15339 SATICOY ST | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914063345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182672600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2007 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 54493 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.