Provider Demographics
NPI:1891908653
Name:LICCIARDELLO, GINA M (LPC)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:M
Last Name:LICCIARDELLO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 BRADFORD TERRACE
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-1803
Mailing Address - Country:US
Mailing Address - Phone:610-444-5879
Mailing Address - Fax:610-444-5079
Practice Address - Street 1:610 MILLERS HILL
Practice Address - Street 2:
Practice Address - City:KENNET SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348
Practice Address - Country:US
Practice Address - Phone:610-444-5879
Practice Address - Fax:610-444-5079
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC001538101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC001538OtherBUREAU OF PROFESSIONAL AN