MEDICARE: ILANA GUSTAFERRO

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	141387	CA

General Provider Information

NPI Number	:	1154103513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILANA GUSTAFERRO

Provider Business Mailing Address
First Line	:	117 AMBER OAKS LN
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91741-6619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 AMBER OAKS LN
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91741-6619
Country	:	US
Telephone Number	:	626-210-8520
Fax Number	:

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

Provider Enumeration Date	:	10/19/2023
Last Update Date	:	10/19/2023

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