MEDICARE: MR. ALEXANDER BRIAN GUSTILO AMFT 136031

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	136031	CA

General Provider Information

NPI Number	:	1073225512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEXANDER BRIAN GUSTILO AMFT 136031

Provider Business Mailing Address
First Line	:	225 W BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1331
Country	:	US
Telephone Number	:	818-441-7800
Fax Number	:	818-441-0013

Provider Business Practice Location Address
First Line	:	225 W BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1331
Country	:	US
Telephone Number	:	818-441-7800
Fax Number	:	818-441-0013

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

Provider Enumeration Date	:	12/15/2022
Last Update Date	:	12/15/2022

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