MEDICARE: GWEN LOTERY MFT

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	LMFT37140	CA

General Provider Information

NPI Number	:	1396940417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWEN LOTERY MFT

Provider Business Mailing Address
First Line	:	12401 WILSHIRE BLVD STE 300
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1087
Country	:	US
Telephone Number	:	310-401-0511
Fax Number	:	310-396-7680

Provider Business Practice Location Address
First Line	:	12401 WILSHIRE BLVD STE 300
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1087
Country	:	US
Telephone Number	:	310-401-0511
Fax Number	:	310-396-7680

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

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	07/08/2007

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