MEDICARE: MRS. GINA MARIE CLAXTON MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	SW13791	FL
3	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1306266507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GINA MARIE CLAXTON MSW

Provider Business Mailing Address
First Line	:	4404 SOUTH FLORIDA AVENUE
Second Line	:	SUITE 301
City	:	LAKELAND
State	:	FL
Zip	:	33813-4053
Country	:	US
Telephone Number	:	863-709-8110
Fax Number	:	863-709-8118

Provider Business Practice Location Address
First Line	:	4404 SOUTH FLORIDA AVENUE
Second Line	:	SUITE 301
City	:	LAKELAND
State	:	FL
Zip	:	33813-4053
Country	:	US
Telephone Number	:	863-709-8110
Fax Number	:	863-709-8118

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2014
Last Update Date	:	09/01/2016

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