Provider Demographics
NPI:1184110215
Name:GLUCK, MIRIAM MADELINE
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:MADELINE
Last Name:GLUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7269 ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-1919
Mailing Address - Country:US
Mailing Address - Phone:213-700-6121
Mailing Address - Fax:
Practice Address - Street 1:7269 ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-1919
Practice Address - Country:US
Practice Address - Phone:213-700-6121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31535106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty