Provider Demographics
NPI:1285333252
Name:MEMOLI, GINO ANTHONY III
Entity type:Individual
Prefix:
First Name:GINO
Middle Name:ANTHONY
Last Name:MEMOLI
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 LEEWARD AVE
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2121
Mailing Address - Country:US
Mailing Address - Phone:203-581-1189
Mailing Address - Fax:
Practice Address - Street 1:11549 LOS OSOS VALLEY RD STE 103
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6457
Practice Address - Country:US
Practice Address - Phone:805-235-7792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0014494106H00000X
TN2552106H00000X
UT14072848-3902106H00000X
CA146784106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist