Provider Demographics
NPI:1497047450
Name:GERIATRIC PSYCHOTHERAPY SERVICES GINA BAX, MSW, LCSW, LLC
Entity Type:Organization
Organization Name:GERIATRIC PSYCHOTHERAPY SERVICES GINA BAX, MSW, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BAX
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:636-577-4607
Mailing Address - Street 1:261 BLESS US DR E
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-2227
Mailing Address - Country:US
Mailing Address - Phone:636-577-4607
Mailing Address - Fax:
Practice Address - Street 1:261 BLESS US DR E
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-2227
Practice Address - Country:US
Practice Address - Phone:636-577-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health