Basic Information
| Provider Information | |||||||||
| NPI: | 1942482625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAZA | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DAZA | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MFT INTERN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1615 FRENCH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927012475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148248140 | ||||||||
| FaxNumber: | 7148248141 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 FRENCH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927012475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148248140 | ||||||||
| FaxNumber: | 7148248141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2007 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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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 | 101YM0800X | 47810 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.