Provider Demographics
NPI:1760691729
Name:GUSTINELLA, MK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MK
Middle Name:
Last Name:GUSTINELLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2842
Mailing Address - Country:US
Mailing Address - Phone:949-262-7880
Mailing Address - Fax:949-955-0163
Practice Address - Street 1:19742 MACARTHUR BLVD STE 125
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2430
Practice Address - Country:US
Practice Address - Phone:949-262-7880
Practice Address - Fax:949-955-0163
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15931103TC0700X
CAMFC20789103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical