Provider Demographics
NPI:1992992218
Name:PINE, GWYNNE GILFORD (MFT)
Entity type:Individual
Prefix:MRS
First Name:GWYNNE
Middle Name:GILFORD
Last Name:PINE
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 1:12402 VENTURA BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2406
Mailing Address - Country:US
Mailing Address - Phone:818-761-7492
Mailing Address - Fax:818-761-2728
Practice Address - Street 1:12402 VENTURA BLVD FL 2
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2406
Practice Address - Country:US
Practice Address - Phone:818-761-7492
Practice Address - Fax:818-761-2728
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 37990106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist