MEDICARE: MS. GINA MARIE FORGETTE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	26403	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2052	OTHER	CA	BILLING NUMBER

General Provider Information

NPI Number	:	1306855630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GINA MARIE FORGETTE LCSW

Provider Business Mailing Address
First Line	:	2178 JOHNSON AVE
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-4535
Country	:	US
Telephone Number	:	805-781-4213
Fax Number	:	805-781-1265

Provider Business Practice Location Address
First Line	:	2975 MCMILLAN AVE
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-6768
Country	:	US
Telephone Number	:	805-781-4213
Fax Number	:	805-781-1265

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	11/20/2024

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