Provider Demographics
NPI:1265822605
Name:MCTAGGART, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MCTAGGART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:11037 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4007
Mailing Address - Country:US
Mailing Address - Phone:800-273-4292
Mailing Address - Fax:949-253-4627
Practice Address - Street 1:11037 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4007
Practice Address - Country:US
Practice Address - Phone:800-273-4292
Practice Address - Fax:949-253-4627
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-17435103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst