Provider Demographics
NPI:1023459229
Name:GAUVREAU, BETHANY S (LCSW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:S
Last Name:GAUVREAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 OCEAN PARK BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3227
Mailing Address - Country:US
Mailing Address - Phone:310-202-6469
Mailing Address - Fax:
Practice Address - Street 1:3301 OCEAN PARK BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3227
Practice Address - Country:US
Practice Address - Phone:310-202-6469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS164511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical