MEDICARE: DR. GREGORY ALLEN PH.D., 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	17674	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER	CA	INS APPLICATION BEING PROCESSED FOR AETNA

General Provider Information

NPI Number	:	1679841795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY ALLEN PH.D., MFT

Provider Business Mailing Address
First Line	:	336 TEJON PL
Second Line	:
City	:	PALOS VERDES ESTATES
State	:	CA
Zip	:	90274-1204
Country	:	US
Telephone Number	:	310-378-9005
Fax Number	:	310-378-3024

Provider Business Practice Location Address
First Line	:	336 TEJON PL
Second Line	:
City	:	PALOS VERDES ESTATES
State	:	CA
Zip	:	90274-1204
Country	:	US
Telephone Number	:	310-378-9005
Fax Number	:	310-378-3024

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

Provider Enumeration Date	:	12/03/2011
Last Update Date	:	12/03/2011

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