=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700540598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA SIMONELLI LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2021
-----------------------------------------------------
Last Update Date | 10/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 881 ALMA REAL DR STE 311
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-713-6739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 S COCHRAN AVE APT 12
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 10246
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPCC8204
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------