Healthcare Provider Details

I. General information

NPI: 1790813558
Provider Name (Legal Business Name): MAUREEN FITZGERALD GENGE CASEMANAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501-4413
US

IV. Provider business mailing address

4168 WILLIAMS ST
EUREKA CA
95503-6473
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-2990
  • Fax:
Mailing address:
  • Phone: 707-445-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number061041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: