MEDICARE: GARY VENTIMIGLIA MFCC

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	102L00000X	Psychoanalyst	MFT21132	CA

General Provider Information

NPI Number	:	1538640818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARY VENTIMIGLIA MFCC

Provider Business Mailing Address
First Line	:	17356 SHERMAN WAY
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91406-3502
Country	:	US
Telephone Number	:	818-497-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	17356 SHERMAN WAY
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91406-3502
Country	:	US
Telephone Number	:	818-497-8000
Fax Number	:

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	GARY VENTIMIGLIA
Credential	:
Telephone Number	:	818-497-8000

Provider Enumeration Date	:	08/24/2018
Last Update Date	:	08/24/2018

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