Provider Demographics
NPI:1972374411
Name:FUDICKAR, GUSTINE (AMFT)
Entity type:Individual
Prefix:MS
First Name:GUSTINE
Middle Name:
Last Name:FUDICKAR
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 HILLHURST AVE # 1356
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2712
Mailing Address - Country:US
Mailing Address - Phone:323-363-9652
Mailing Address - Fax:
Practice Address - Street 1:1800 S BRAND BLVD STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-3550
Practice Address - Country:US
Practice Address - Phone:323-363-9652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist