Provider Demographics
NPI:1366736753
Name:GALLIVAN, GINA (PHD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:
Last Name:GALLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5182 KATELLA AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2824
Mailing Address - Country:US
Mailing Address - Phone:562-493-4655
Mailing Address - Fax:562-493-8897
Practice Address - Street 1:5182 KATELLA AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2824
Practice Address - Country:US
Practice Address - Phone:562-493-4655
Practice Address - Fax:562-493-8897
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18184103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical