MEDICARE: DR. GISLENE MARIETTE PH.C.

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 15317	CA

General Provider Information

NPI Number	:	1528235546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GISLENE MARIETTE PH.C.

Provider Business Mailing Address
First Line	:	PO BOX 361362
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-9346
Country	:	US
Telephone Number	:	310-677-1247
Fax Number	:

Provider Business Practice Location Address
First Line	:	5455 WILSHIRE BLVD
Second Line	:	2109
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4201
Country	:	US
Telephone Number	:	310-677-1247
Fax Number	:

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

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	05/08/2008

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