=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295084846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA LYNN DICK MA, LMHCA, NCACI, CD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2012
-----------------------------------------------------
Last Update Date | 08/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 NE RIDDELL RD STE 314
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98310-3693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-373-4077
-----------------------------------------------------
Fax | 360-792-0362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 NE RIDDELL RD STE 314
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98310-3693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-373-4077
-----------------------------------------------------
Fax | 360-792-0362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | CG60201203
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CP00006322
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MC60210692
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------