Provider Demographics
NPI:1457643348
Name:IACIOFANO, GINA MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:IACIOFANO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 WOODWARD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-3139
Mailing Address - Country:US
Mailing Address - Phone:401-497-6500
Mailing Address - Fax:
Practice Address - Street 1:1445 WAMPANOAG TRL
Practice Address - Street 2:SUITE 106
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-1000
Practice Address - Country:US
Practice Address - Phone:401-437-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW021211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical