Provider Demographics
NPI:1851050942
Name:GUCKENBURG, GINELLE (AMFT #125133)
Entity Type:Individual
Prefix:
First Name:GINELLE
Middle Name:
Last Name:GUCKENBURG
Suffix:
Gender:F
Credentials:AMFT #125133
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 E QUEEN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4832
Mailing Address - Country:US
Mailing Address - Phone:909-684-0237
Mailing Address - Fax:
Practice Address - Street 1:2309 PACIFIC COAST HWY STE 104
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2752
Practice Address - Country:US
Practice Address - Phone:424-265-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125133101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health