Provider Demographics
NPI:1083710594
Name:GENGO, PAMELA SUZANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SUZANNE
Last Name:GENGO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BANNING MENTAL HEALTH CLINIC
Mailing Address - Street 2:P.O. BOX 1148
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4448
Mailing Address - Country:US
Mailing Address - Phone:951-849-7142
Mailing Address - Fax:
Practice Address - Street 1:1330 W RAMSEY ST STE 100
Practice Address - Street 2:BANNING MENTAL HEALTH CLINIC
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4448
Practice Address - Country:US
Practice Address - Phone:951-849-7142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical