Provider Demographics
NPI:1083896021
Name:MIDYETT, GINA REBECCA (MA)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:REBECCA
Last Name:MIDYETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16106 DARNELL RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-3701
Mailing Address - Country:US
Mailing Address - Phone:813-454-9656
Mailing Address - Fax:
Practice Address - Street 1:16106 DARNELL RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-3701
Practice Address - Country:US
Practice Address - Phone:813-454-9656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH5698101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health