Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225C00000X | Rehabilitation Counselor |
NPI | 1104593342 |
---|---|
Provider Name | Gayane Elizabeth Pettibone |
First Address | Los Angeles, CA 90034-3740 |
Second Address | Los Angeles, CA 90034-3740 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2021 |
Last Update Date | 25/08/2021 |