Provider Demographics
NPI:1265500664
Name:UNDERWOOD, GINA MICHELE (LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MICHELE
Last Name:UNDERWOOD
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 1:614 CENTRAL AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-1793
Mailing Address - Country:US
Mailing Address - Phone:859-227-4676
Mailing Address - Fax:502-875-1686
Practice Address - Street 1:4 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4181
Practice Address - Country:US
Practice Address - Phone:502-875-1685
Practice Address - Fax:502-875-1686
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY16301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY611469160OtherTAX ID & HUMANA&BGFH ID #
KY1216008OtherCHA HEALTH ID #
KY775407000OtherMAGELLAN BEH HEALTH ID #
KY000000336984OtherANTHEM BC BS ID #
KY7495652OtherAETNA PROVIDER ID #