Provider Demographics
NPI:1952518284
Name:FELTON, GARY SPENCER
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:SPENCER
Last Name:FELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:SPENCER
Other - Last Name:FELTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, PHD
Mailing Address - Street 1:10780 SANTA MONICA BLVD STE 450
Mailing Address - Street 2:SUITE #450
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7635
Mailing Address - Country:US
Mailing Address - Phone:310-281-5531
Mailing Address - Fax:310-559-8743
Practice Address - Street 1:10780 SANTA MONICA BLVD STE 450 SUITE 450
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7635
Practice Address - Country:US
Practice Address - Phone:310-281-5531
Practice Address - Fax:310-559-8743
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY3673103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY3673OtherSTATE LICENSE NUMBER
CAPSY3673OtherSTATE LICENSE NUMBER