Healthcare Provider Details

I. General information

NPI: 1295714970
Provider Name (Legal Business Name): GINA M CIVEROLO M.A. LPCC DAPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 ALAMO AVE SE C/O ASAP
ALBUQUERQUE NM
87106-3204
US

IV. Provider business mailing address

933 BRADBURY DR SE
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-2400
  • Fax: 505-925-2411
Mailing address:
  • Phone: 505-272-3120
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1482
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: