Basic Information
| Provider Information | |||||||||
| NPI: | 1295714970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIVEROLO | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A. LPCC DAPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 ALAMO AVE SE | ||||||||
| Address2: | C/O ASAP | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871063204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059252400 | ||||||||
| FaxNumber: | 5059252411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1482 | NM | Y | Other Service Providers | Specialist |
No ID Information.