Provider Demographics
NPI:1053844787
Name:VANCE, GINA (CCHT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 BRIDGEWAY
Mailing Address - Street 2:STE 242
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-2810
Mailing Address - Country:US
Mailing Address - Phone:415-275-4221
Mailing Address - Fax:
Practice Address - Street 1:3030 BRIDGEWAY
Practice Address - Street 2:STE 242
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-2810
Practice Address - Country:US
Practice Address - Phone:415-275-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACCHT174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist