Provider Demographics
NPI:1528235546
Name:MARIETTE, GISLENE (PHC)
Entity type:Individual
Prefix:DR
First Name:GISLENE
Middle Name:
Last Name:MARIETTE
Suffix:
Gender:F
Credentials:PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361362
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-9346
Mailing Address - Country:US
Mailing Address - Phone:310-677-1247
Mailing Address - Fax:
Practice Address - Street 1:5455 WILSHIRE BLVD
Practice Address - Street 2:2109
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4201
Practice Address - Country:US
Practice Address - Phone:310-677-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15317103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical