Provider Demographics
NPI:1356518583
Name:HANSEN, GWENDOLINE (MA MPT LIC MFT27233)
Entity type:Individual
Prefix:
First Name:GWENDOLINE
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MA MPT LIC MFT27233
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4741 LAUREL CYN BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607
Mailing Address - Country:US
Mailing Address - Phone:818-763-9977
Mailing Address - Fax:
Practice Address - Street 1:4741 LAUREL CYN BLVD
Practice Address - Street 2:#105
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607
Practice Address - Country:US
Practice Address - Phone:818-763-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT27233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist