MEDICARE: DR. MARIA AVILA GENGENBACHER PSY.D.

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	103TC0700X	Clinical Psychologist	PSY 21014	CA

General Provider Information

NPI Number	:	1508098021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIA AVILA GENGENBACHER PSY.D.

Provider Business Mailing Address
First Line	:	4929 WILSHIRE BLVD STE 510
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3820
Country	:	US
Telephone Number	:	888-307-0893
Fax Number	:	310-734-5511

Provider Business Practice Location Address
First Line	:	4929 WILSHIRE BLVD STE 510
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3820
Country	:	US
Telephone Number	:	888-307-0893
Fax Number	:	310-734-5511

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

Provider Enumeration Date	:	08/17/2009
Last Update Date	:	04/10/2019

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