Basic Information
| Provider Information | |||||||||
| NPI: | 1013053164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAGE | ||||||||
| FirstName: | ELENI | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 MAPLEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | STRUTHERS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444711136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307509373 | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445021037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307442991 | ||||||||
| FaxNumber: | 3307442971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C0005048 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000000126036 | 01 | OH | ANTHEM BC BS | OTHER |