MEDICARE: RAPHAEL I GUNNER 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	PSY19173	CA

General Provider Information

NPI Number	:	1619993326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAPHAEL I GUNNER PSY.D

Provider Business Mailing Address
First Line	:	1644 COLBY AVE APT 6
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-3051
Country	:	US
Telephone Number	:	310-583-8552
Fax Number	:	310-941-9124

Provider Business Practice Location Address
First Line	:	2001 S BARRINGTON AVE STE 202
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-5385
Country	:	US
Telephone Number	:	310-570-1919
Fax Number	:	310-914-9124

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/08/2007

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