Provider Demographics
NPI:1720397912
Name:DIARCHANGEL, GINA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:DIARCHANGEL
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 1:5110 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3424
Mailing Address - Country:US
Mailing Address - Phone:800-275-3243
Mailing Address - Fax:800-275-3671
Practice Address - Street 1:157 BROAD ST STE 301
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2013
Practice Address - Country:US
Practice Address - Phone:322-399-2687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05168900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical