=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851945042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTINE AMBER GORDON NONE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2019
-----------------------------------------------------
Last Update Date | 10/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4760 SEPULVEDA BLVD
-----------------------------------------------------
City | CULVER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90230-4820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-652-4358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3171 W OLYMPIC BLVD # 114
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90006-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | AMFT126587
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------