MEDICARE: GWEN GRABB 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	MFC42684	CA

General Provider Information

NPI Number	:	1467695445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWEN GRABB MFT

Provider Business Mailing Address
First Line	:	334 TEJON PLACE
Second Line	:
City	:	PALOS VERDES ESTATES
State	:	CA
Zip	:	90274-1204
Country	:	US
Telephone Number	:	310-880-3981
Fax Number	:	815-717-7625

Provider Business Practice Location Address
First Line	:	334 TEJON PL
Second Line	:
City	:	PALOS VERDES ESTATES
State	:	CA
Zip	:	90274-1204
Country	:	US
Telephone Number	:	310-880-3981
Fax Number	:	815-717-7625

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

Provider Enumeration Date	:	04/07/2009
Last Update Date	:	04/07/2009

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