Provider Demographics
NPI:1194167833
Name:GENSAW, LINDA ZORAIDA (NONE)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:ZORAIDA
Last Name:GENSAW
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12406 CEDAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8736
Mailing Address - Country:US
Mailing Address - Phone:773-818-8060
Mailing Address - Fax:
Practice Address - Street 1:12406 CEDAR LAKE RD
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8736
Practice Address - Country:US
Practice Address - Phone:773-818-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1830-23-8598347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN101785485099Medicaid