=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669973152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GWENDOLYN NELSON-TERRY, LMFT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2018
-----------------------------------------------------
Last Update Date | 02/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4080 CENTRE ST STE 202
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-2657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-383-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1760 S EL CAMINO REAL UNIT D206
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-4975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-678-0186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | GWENDOLYN ERIN NELSON-TERRY
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 415-678-0186
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 84535
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------