Provider Demographics
NPI:1205231842
Name:STANGO, GINA MARIE MATTIVI (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE MATTIVI
Last Name:STANGO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 VETERANS SQ
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3155
Mailing Address - Country:US
Mailing Address - Phone:610-744-2526
Mailing Address - Fax:610-514-9849
Practice Address - Street 1:24 VETERANS SQ
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3155
Practice Address - Country:US
Practice Address - Phone:610-744-2526
Practice Address - Fax:610-514-9849
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0179671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical