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NPI Code Detail

MEDICARE: MS. GENA DAWN PONTICELLI

MEDICARE: MS. GENA DAWN PONTICELLI
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
1106H00000XMarriage & Family Therapist52862CA

General Provider Information

NPI Number : 1265791081
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. GENA DAWN PONTICELLI
Provider Business Mailing Address
First Line : 1600 W IMPERIAL HWY
Second Line :
City : LOS ANGELES
State : CA
Zip : 90047-4810
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1600 W IMPERIAL HWY
Second Line :
City : LOS ANGELES
State : CA
Zip : 90047-4810
Country : US
Telephone Number : 800-777-9311
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/14/2012
Last Update Date : 01/10/2014

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Directions to “ MS. GENA DAWN PONTICELLI ” Practice Location

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