Provider Demographics
NPI:1376339515
Name:GHOLSTON, ALEXIS (AMFT)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:GHOLSTON
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 1:4960 LINSCOTT PL APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-5420
Mailing Address - Country:US
Mailing Address - Phone:937-524-3942
Mailing Address - Fax:
Practice Address - Street 1:12424 WILSHIRE BLVD STE 650
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1081
Practice Address - Country:US
Practice Address - Phone:937-524-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA149593106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty