Provider Demographics
NPI:1306855630
Name:FORGETTE, GINA MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:MARIE
Last Name:FORGETTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4535
Mailing Address - Country:US
Mailing Address - Phone:805-781-4213
Mailing Address - Fax:805-781-1265
Practice Address - Street 1:2975 MCMILLAN AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6768
Practice Address - Country:US
Practice Address - Phone:805-781-4213
Practice Address - Fax:805-781-1265
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA264031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2052OtherBILLING NUMBER