Provider Demographics
NPI:1528451499
Name:SIQUEIROS, GINA MARIE (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:SIQUEIROS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 N COAST HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-2357
Mailing Address - Country:US
Mailing Address - Phone:541-505-0870
Mailing Address - Fax:
Practice Address - Street 1:1642 N COAST HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-2357
Practice Address - Country:US
Practice Address - Phone:541-505-0870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health