Healthcare Provider Details

I. General information

NPI: 1811986797
Provider Name (Legal Business Name): MICHAEL G GINGERICH LCSW, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 H ST SUITE 2N
CRESCENT CITY CA
95531-3736
US

IV. Provider business mailing address

550 H ST SUITE 2N
CRESCENT CITY CA
95531-3736
US

V. Phone/Fax

Practice location:
  • Phone: 707-464-6075
  • Fax: 707-464-1898
Mailing address:
  • Phone: 707-464-6075
  • Fax: 707-464-1898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS4154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: