=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679869341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIRGINIA GAETA NAGIEC QP, MS, LMFTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2011
-----------------------------------------------------
Last Update Date | 12/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 MANOMET AVE
-----------------------------------------------------
City | HULL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02045-2341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-925-2423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 JERSEY ST APT C
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02215-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-259-7278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 7066A
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1440
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------