Provider Demographics
NPI:1730251455
Name:KING, GINA MARY (LICSW)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARY
Last Name:KING
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2327
Mailing Address - Country:US
Mailing Address - Phone:978-287-5440
Mailing Address - Fax:
Practice Address - Street 1:4 STRAWBERRY HILL RD
Practice Address - Street 2:LEVEL 2
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-5757
Practice Address - Country:US
Practice Address - Phone:978-264-2951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10161861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23505Medicare ID - Type Unspecified