Provider Demographics
NPI:1326744855
Name:BRUNELLI, GINA TABER (LMFT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:TABER
Last Name:BRUNELLI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4804 IROQUOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6248
Mailing Address - Country:US
Mailing Address - Phone:925-918-3004
Mailing Address - Fax:
Practice Address - Street 1:4510 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3021
Practice Address - Country:US
Practice Address - Phone:925-918-3004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136549106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist