Provider Demographics
NPI:1508098021
Name:GENGENBACHER, MARIA AVILA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:AVILA
Last Name:GENGENBACHER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4929 WILSHIRE BLVD STE 510
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3820
Mailing Address - Country:US
Mailing Address - Phone:888-307-0893
Mailing Address - Fax:310-734-5511
Practice Address - Street 1:4929 WILSHIRE BLVD STE 510
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3820
Practice Address - Country:US
Practice Address - Phone:888-307-0893
Practice Address - Fax:310-734-5511
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21014103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical