Provider Demographics
NPI:1700954062
Name:WEST, GINA (MFT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2716
Mailing Address - Country:US
Mailing Address - Phone:336-631-1144
Mailing Address - Fax:
Practice Address - Street 1:632 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2716
Practice Address - Country:US
Practice Address - Phone:336-631-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC717106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist