MEDICARE: GREGORY C OWENS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1023509346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY C OWENS

Provider Business Mailing Address
First Line	:	1747 W 39TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90062-1057
Country	:	US
Telephone Number	:	310-344-9441
Fax Number	:

Provider Business Practice Location Address
First Line	:	1747 W 39TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90062-1057
Country	:	US
Telephone Number	:	310-344-9441
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2018
Last Update Date	:	05/22/2018

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