Provider Demographics
NPI:1114579141
Name:FASOLINO, GINA LERAY
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:LERAY
Last Name:FASOLINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 HUNTINGTON DR APT 51
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7675
Mailing Address - Country:US
Mailing Address - Phone:530-783-9461
Mailing Address - Fax:
Practice Address - Street 1:560 COHASSET RD STE 180
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2460
Practice Address - Country:US
Practice Address - Phone:530-891-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty