Healthcare Provider Details

I. General information

NPI: 1376773184
Provider Name (Legal Business Name): BEDA GAMBOA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4816 E 3RD ST
LOS ANGELES CA
90022-1602
US

IV. Provider business mailing address

4816 E 3RD ST
LOS ANGELES CA
90022-1602
US

V. Phone/Fax

Practice location:
  • Phone: 323-780-4510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number22123
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: