Provider Demographics
NPI:1073225512
Name:GUSTILO, ALEXANDER BRIAN (AMFT 136031)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:BRIAN
Last Name:GUSTILO
Suffix:
Gender:M
Credentials:AMFT 136031
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1331
Mailing Address - Country:US
Mailing Address - Phone:818-441-7800
Mailing Address - Fax:818-441-0013
Practice Address - Street 1:225 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1331
Practice Address - Country:US
Practice Address - Phone:818-441-7800
Practice Address - Fax:818-441-0013
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136031106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist