Provider Demographics
NPI:1124217062
Name:GAVRIEL, MARINA (MH)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:GAVRIEL
Suffix:
Gender:F
Credentials:MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 S SHENANDOAH ST
Mailing Address - Street 2:APT #303
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-4477
Mailing Address - Country:US
Mailing Address - Phone:818-804-1205
Mailing Address - Fax:
Practice Address - Street 1:15339 SATICOY ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3345
Practice Address - Country:US
Practice Address - Phone:818-267-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54493101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health