Provider Demographics
NPI:1558571307
Name:MEREDITH, GORDON WHITTAKER (MFT, CGP)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:WHITTAKER
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:MFT, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MARINE VIEW AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2122
Mailing Address - Country:US
Mailing Address - Phone:858-481-4982
Mailing Address - Fax:
Practice Address - Street 1:140 MARINE VIEW AVE STE 104
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2122
Practice Address - Country:US
Practice Address - Phone:858-481-4982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC20795106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist