Provider Demographics
NPI:1154662021
Name:PATOVISTI, GINA (LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:PATOVISTI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:ROELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1717 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2405
Mailing Address - Country:US
Mailing Address - Phone:262-638-6673
Mailing Address - Fax:
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-638-6673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7915-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical