Provider Demographics
NPI:1215961636
Name:REZNICHEK, CAROL GAINOR (MFT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:GAINOR
Last Name:REZNICHEK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 SEPULVEDA BLVD
Mailing Address - Street 2:#30
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266
Mailing Address - Country:US
Mailing Address - Phone:310-630-9717
Mailing Address - Fax:
Practice Address - Street 1:2100 SEPULVEDA BLVD
Practice Address - Street 2:#30
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266
Practice Address - Country:US
Practice Address - Phone:310-630-9717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31388106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist