MEDICARE: DR. MK GUSTINELLA PH.D

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	103TC0700X	Clinical Psychologist	PSY15931	CA
2	103TC0700X	Clinical Psychologist	MFC20789	CA

General Provider Information

NPI Number	:	1760691729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MK GUSTINELLA PH.D

Provider Business Mailing Address
First Line	:	959 MEADOWLARK LN
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2842
Country	:	US
Telephone Number	:	949-262-7880
Fax Number	:	949-955-0163

Provider Business Practice Location Address
First Line	:	19742 MACARTHUR BLVD STE 125
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92612-2430
Country	:	US
Telephone Number	:	949-262-7880
Fax Number	:	949-955-0163

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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