MEDICARE: GWEN'S HOUSE MARRIAGE AND FAMILY THERAPY, INC.

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

General Provider Information

NPI Number	:	1598343493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GWEN'S HOUSE MARRIAGE AND FAMILY THERAPY, INC.

Provider Business Mailing Address
First Line	:	10416 PROSPECTOR LN
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92557-4237
Country	:	US
Telephone Number	:	951-823-4394
Fax Number	:

Provider Business Practice Location Address
First Line	:	7190 W SUNSET BLVD # 62D
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-4415
Country	:	US
Telephone Number	:	917-409-7719
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	SHANET DENNIS
Credential	:	LMFT
Telephone Number	:	917-409-7719

Provider Enumeration Date	:	03/31/2021
Last Update Date	:	03/31/2021

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