Provider Demographics
NPI:1700011202
Name:NINIVAGGIO, GENA H (LCSW)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:H
Last Name:NINIVAGGIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5401
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-1401
Mailing Address - Country:US
Mailing Address - Phone:707-317-3208
Mailing Address - Fax:
Practice Address - Street 1:1600 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-448-6841
Practice Address - Fax:707-453-7015
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS217931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical