MEDICARE: TREVOR P GJELTEMA IMF

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	106H00000X	Marriage & Family Therapist	IMF 69063	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265770101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREVOR P GJELTEMA IMF

Provider Business Mailing Address
First Line	:	1907 28TH ST APT B
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-7338
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1907 28TH ST APT B
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-7338
Country	:	US
Telephone Number	:	831-234-4835
Fax Number	:

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

Provider Enumeration Date	:	01/28/2013
Last Update Date	:	02/11/2022

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