Provider Demographics
NPI:1497348957
Name:GOST, MARIANA N (MA)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:N
Last Name:GOST
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 AVIATION BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4059
Mailing Address - Country:US
Mailing Address - Phone:310-376-2468
Mailing Address - Fax:
Practice Address - Street 1:1200 AVIATION BLVD STE 100
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-4059
Practice Address - Country:US
Practice Address - Phone:310-376-2468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95685106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty