Healthcare Provider Details

I. General information

NPI: 1588340525
Provider Name (Legal Business Name): MAGGIE GWINN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 26TH ST STE 205
SANTA MONICA CA
90402-2543
US

IV. Provider business mailing address

270 26TH ST STE 205
SANTA MONICA CA
90402-2543
US

V. Phone/Fax

Practice location:
  • Phone: 310-476-0109
  • Fax:
Mailing address:
  • Phone: 310-476-0109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC25533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: