Provider Demographics
NPI:1396873089
Name:GOURDINE, I REGINA (MSW , LCSW)
Entity type:Individual
Prefix:MISS
First Name:I REGINA
Middle Name:
Last Name:GOURDINE
Suffix:
Gender:F
Credentials:MSW , LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9378 OLIVE BLVD STE 311
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3224
Mailing Address - Country:US
Mailing Address - Phone:314-845-3502
Mailing Address - Fax:314-329-6858
Practice Address - Street 1:9378 OLIVE BLVD STE 311
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3224
Practice Address - Country:US
Practice Address - Phone:314-845-3502
Practice Address - Fax:314-329-6858
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374U00000X, 376J00000X
101YP1600X
MO0042141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493656805Medicaid