=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689845927
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GINA V EATON LCSW PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2008
-----------------------------------------------------
Last Update Date | 03/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5400 S UNIVERSITY DR SUITE #207
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-370-3335
-----------------------------------------------------
Fax | 954-370-3353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5400 S UNIVERSITY DR SUITE #207
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-370-3335
-----------------------------------------------------
Fax | 954-370-3353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GINA V EATON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 954-370-3335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3884
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------