Provider Demographics
NPI:1801023775
Name:MOORE, GINA BORELLI (MA, MFT)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:BORELLI
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 LINCOLN AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2143
Mailing Address - Country:US
Mailing Address - Phone:415-460-6390
Mailing Address - Fax:415-532-1587
Practice Address - Street 1:1330 LINCOLN AVE STE 301
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2143
Practice Address - Country:US
Practice Address - Phone:415-460-6390
Practice Address - Fax:415-532-1587
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 35071106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist