Provider Demographics
NPI:1275068637
Name:HART, GINA (LCSW, LADC1)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:LCSW, LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PENNYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-1010
Mailing Address - Country:US
Mailing Address - Phone:617-653-4087
Mailing Address - Fax:
Practice Address - Street 1:29 PENNYBROOK RD
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905
Practice Address - Country:US
Practice Address - Phone:617-653-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15280101YA0400X
MA221793101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health