Healthcare Provider Details

I. General information

NPI: 1962126318
Provider Name (Legal Business Name): GISSELLA MIA ALTAMIRANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16360 ROSCOE BLVD FL 2
VAN NUYS CA
91406-1219
US

IV. Provider business mailing address

14819 SHERMAN WAY UNIT 9
VAN NUYS CA
91405-2263
US

V. Phone/Fax

Practice location:
  • Phone: 818-901-4830
  • Fax:
Mailing address:
  • Phone: 818-287-9613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number147415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: