Provider Demographics
NPI:1659530988
Name:GOLLNICK, LAURA EMILY (MS,MFT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EMILY
Last Name:GOLLNICK
Suffix:
Gender:F
Credentials:MS,MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 STONEHILL DR
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-1541
Mailing Address - Country:US
Mailing Address - Phone:626-794-9260
Mailing Address - Fax:
Practice Address - Street 1:2945 STONEHILL DR
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-1541
Practice Address - Country:US
Practice Address - Phone:626-794-9260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 21430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist