Basic Information
| Provider Information | |||||||||
| NPI: | 1265945430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAGENA | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COSCHINO | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 510220 | ||||||||
| Address2: | |||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1050 WILSHIRE DR STE 175 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2017 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801100943 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801100943 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 6801105830 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.