Healthcare Provider Details

I. General information

NPI: 1578285466
Provider Name (Legal Business Name): DIMITRI GATSIOUNIS M.A./MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11785 LAURELWOOD DR APT 1
STUDIO CITY CA
91604-3705
US

IV. Provider business mailing address

11785 LAURELWOOD DR APT 1
STUDIO CITY CA
91604-3705
US

V. Phone/Fax

Practice location:
  • Phone: 323-842-8667
  • Fax:
Mailing address:
  • Phone: 323-842-8667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number111049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: