Provider Demographics
NPI:1194003608
Name:ATENCIO-MACLEAN, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:ATENCIO-MACLEAN
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 1:629 CAMINO DE LOS MARES
Mailing Address - Street 2:STE 207A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2832
Mailing Address - Country:US
Mailing Address - Phone:949-228-9080
Mailing Address - Fax:844-602-4623
Practice Address - Street 1:647 CAMINO DE LOS MARES STE 221
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2807
Practice Address - Country:US
Practice Address - Phone:949-228-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2855103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical