Provider Demographics
NPI:1558748228
Name:GLUCK, PAULA (MFTI)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:GLUCK
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017
Mailing Address - Country:US
Mailing Address - Phone:213-481-7464
Mailing Address - Fax:213-481-7147
Practice Address - Street 1:204 HAMPTON DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2623
Practice Address - Country:US
Practice Address - Phone:310-396-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF90350106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL