Provider Demographics
NPI:1558646042
Name:ACOSTA, GLORIA RUBIO
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:RUBIO
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:GLORIA
Other - Middle Name:RUBIO
Other - Last Name:ACOSTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:18646 OXNARD ST.
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:310-709-5652
Mailing Address - Fax:
Practice Address - Street 1:4230 1/2 W 101ST ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90304-1542
Practice Address - Country:US
Practice Address - Phone:310-709-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN2484279101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor