Provider Demographics
NPI:1174674162
Name:CONSTANTINI, GINA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:CONSTANTINI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:MAVROMATIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:241 MAIN ST
Mailing Address - Street 2:B
Mailing Address - City:BLAKELY
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1233
Mailing Address - Country:US
Mailing Address - Phone:570-947-3163
Mailing Address - Fax:
Practice Address - Street 1:5 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JERMYN
Practice Address - State:PA
Practice Address - Zip Code:18433-1121
Practice Address - Country:US
Practice Address - Phone:570-230-0019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0158031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
117893SM7Medicare UPIN
PA117893V6HMedicare PIN