MEDICARE: MRS. GWYNNE GILFORD PINE MFT

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	106H00000X	Marriage & Family Therapist	MFC 37990	CA

General Provider Information

NPI Number	:	1992992218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GWYNNE GILFORD PINE MFT

Provider Business Mailing Address
First Line	:	12402 VENTURA BLVD FL 2
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2406
Country	:	US
Telephone Number	:	818-761-7492
Fax Number	:	818-761-2728

Provider Business Practice Location Address
First Line	:	12402 VENTURA BLVD FL 2
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2406
Country	:	US
Telephone Number	:	818-761-7492
Fax Number	:	818-761-2728

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

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	10/01/2007

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