Provider Demographics
NPI:1083960413
Name:GULSRUD, AMANDA (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GULSRUD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 WESTWOOD PLZ
Mailing Address - Street 2:RM 68-237C
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5055
Mailing Address - Country:US
Mailing Address - Phone:310-825-0575
Mailing Address - Fax:
Practice Address - Street 1:760 WESTWOOD PLZ
Practice Address - Street 2:RM 68-237C
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5055
Practice Address - Country:US
Practice Address - Phone:310-825-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24771103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083960413Medicaid
CA1083960413Medicaid