Provider Demographics
NPI:1679185565
Name:WEIDOW, GINA (LSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WEIDOW
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-2545
Mailing Address - Country:US
Mailing Address - Phone:570-904-7363
Mailing Address - Fax:570-348-4079
Practice Address - Street 1:480 PIERCE ST STE 316
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5512
Practice Address - Country:US
Practice Address - Phone:570-904-7363
Practice Address - Fax:570-348-4079
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW126264104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker