Provider Demographics
NPI:1417529025
Name:HABLI, GINA DAVIDSON (LCAS-A)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:DAVIDSON
Last Name:HABLI
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 ALAMANCE RD STE D
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-6178
Mailing Address - Country:US
Mailing Address - Phone:336-350-7858
Mailing Address - Fax:
Practice Address - Street 1:408 ALAMANCE RD STE D
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-6178
Practice Address - Country:US
Practice Address - Phone:336-350-7858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24248101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
21683OtherPROVIDER ID
NC21683Medicaid