Provider Demographics
NPI:1083377915
Name:MENA, GEORGINA R
Entity Type:Individual
Prefix:MS
First Name:GEORGINA
Middle Name:R
Last Name:MENA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:GEORGINA
Other - Middle Name:R
Other - Last Name:MENA ROSAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ROSAS
Mailing Address - Street 1:1108 CRANBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27205-2334
Mailing Address - Country:US
Mailing Address - Phone:336-523-4910
Mailing Address - Fax:
Practice Address - Street 1:111 POMONA DR STE G
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1636
Practice Address - Country:US
Practice Address - Phone:336-855-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician