Healthcare Provider Details

I. General information

NPI: 1366053340
Provider Name (Legal Business Name): MEGAN ELIZABETH GRAVENSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 E FOOTHILL BLVD
PASADENA CA
91107-3439
US

IV. Provider business mailing address

9942 CULVER BLVD UNIT 361
CULVER CITY CA
90232-4119
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2261
  • Fax:
Mailing address:
  • Phone: 818-996-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number119711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: