Healthcare Provider Details

I. General information

NPI: 1780164061
Provider Name (Legal Business Name): GABRIELLE N KUBULAN-SIMMONS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N GRAND AVE
COVINA CA
91724-2005
US

IV. Provider business mailing address

160 E 3RD ST APT C
POMONA CA
91766-1803
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-2089
  • Fax: 626-859-6537
Mailing address:
  • Phone: 909-230-3902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberACSW83821
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: