Provider Demographics
NPI:1396206827
Name:GASTON, GINA BLANCHE (MSW, PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:BLANCHE
Last Name:GASTON
Suffix:
Gender:F
Credentials:MSW, PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 S LAKE PARK AVE APT 405A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2044
Mailing Address - Country:US
Mailing Address - Phone:773-905-4626
Mailing Address - Fax:
Practice Address - Street 1:820 S. DAMEN
Practice Address - Street 2:ROOM 8434
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-569-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0091901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical