Provider Demographics
NPI:1023698347
Name:POLESETSKY, GINA O'LEARY KIRKLAND (AMFT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:O'LEARY KIRKLAND
Last Name:POLESETSKY
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9696 CULVER BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2759
Mailing Address - Country:US
Mailing Address - Phone:323-362-6468
Mailing Address - Fax:
Practice Address - Street 1:9696 CULVER BLVD STE 303
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2759
Practice Address - Country:US
Practice Address - Phone:323-362-6468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-11
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12425106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist