Healthcare Provider Details

I. General information

NPI: 1356625636
Provider Name (Legal Business Name): GINA MARIE GREGORY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 VENICE BLVD # 15A
LOS ANGELES CA
90006-5108
US

IV. Provider business mailing address

6221 GEARY BLVD
SAN FRANCISCO CA
94121-1887
US

V. Phone/Fax

Practice location:
  • Phone: 310-220-0350
  • Fax:
Mailing address:
  • Phone: 415-474-7310
  • Fax: 415-751-3226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904011119
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73689
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09926035
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number020630
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number68047
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: