MEDICARE: DR. MARYLIE W. GERSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY9102	CA

General Provider Information

NPI Number	:	1194742155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYLIE W. GERSON PH.D.

Provider Business Mailing Address
First Line	:	32129 LINDERO CANYON RD STE 201
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-5433
Country	:	US
Telephone Number	:	818-889-6734
Fax Number	:	818-889-4175

Provider Business Practice Location Address
First Line	:	32129 LINDERO CANYON RD STE 201
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-5433
Country	:	US
Telephone Number	:	818-889-6734
Fax Number	:	818-889-4175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	07/08/2007

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