Provider Demographics
NPI:1619993326
Name:GUNNER, RAPHAEL I (PSYD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:I
Last Name:GUNNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 COLBY AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3051
Mailing Address - Country:US
Mailing Address - Phone:310-583-8552
Mailing Address - Fax:310-941-9124
Practice Address - Street 1:2001 S BARRINGTON AVE STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5385
Practice Address - Country:US
Practice Address - Phone:310-570-1919
Practice Address - Fax:310-914-9124
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical