Provider Demographics
NPI:1851366736
Name:DEFALCO, GINA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:DEFALCO
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 1:485 HUNTINGTON RD
Mailing Address - Street 2:STE 201
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1845
Mailing Address - Country:US
Mailing Address - Phone:706-546-8440
Mailing Address - Fax:706-546-8456
Practice Address - Street 1:485 HUNTINGTON RD
Practice Address - Street 2:STE 201
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-1845
Practice Address - Country:US
Practice Address - Phone:706-546-8440
Practice Address - Fax:706-546-8456
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW002441104100000X
GACSW0042281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker