=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891070017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGE GAMEZ, PHD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2011
-----------------------------------------------------
Last Update Date | 10/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18345 VENTURA BLVD STE 300
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-4242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-655-8777
-----------------------------------------------------
Fax | 310-475-8236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 34850
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-0850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-655-8777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. GEORGE GAMEZ
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 310-475-5236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY 5172
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------