Provider Demographics
NPI:1881008043
Name:AZZAM-FORNI, GABRIELLA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GABRIELLA
Middle Name:
Last Name:AZZAM-FORNI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10780 SANTA MONICA BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4777
Mailing Address - Country:US
Mailing Address - Phone:424-341-4224
Mailing Address - Fax:
Practice Address - Street 1:10780 SANTA MONICA BLVD STE 290
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4777
Practice Address - Country:US
Practice Address - Phone:424-341-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024328103TC0700X
CAPSY29357103TC0700X
TX40000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty