Basic Information
| Provider Information | |||||||||
| NPI: | 1356625636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6221 GEARY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941211887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154747310 | ||||||||
| FaxNumber: | 4157513226 | ||||||||
| Practice Location | |||||||||
| Address1: | 2240 VENICE BLVD # 15A | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900065108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102200350 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2011 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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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 | 1041C0700X | 0904011119 | VA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 73689 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 09926035 | CO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 020630 | PA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 68047 | TX | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.