Provider Demographics
NPI:1386684157
Name:LOVE, GINA MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:LOVE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-742-9243
Mailing Address - Fax:888-746-1787
Practice Address - Street 1:2101 DUTCH FORK RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-7576
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011905103TC0700X
SC1372103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H10569OtherBCBS FOR A2 OFFICE
MI300040030OtherNPC TAX ID
MI477747OtherNPC VO
MI0N81300001Medicare ID - Type UnspecifiedNPC GROUP MEDICARE
MI680F333080OtherPERS BC PIN
MI0M91440009Medicare ID - Type Unspecified
MI680F321030OtherNPC BC GROUP
MIMI5508OtherMCR PIN FOR A2 OFFICE
MIP53768Medicare UPIN