Provider Demographics
NPI:1902028160
Name:DELGARDO, GINA M (PHD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:DELGARDO
Suffix:
Gender:F
Credentials:PHD
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 450067
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33345-0067
Mailing Address - Country:US
Mailing Address - Phone:954-683-9358
Mailing Address - Fax:
Practice Address - Street 1:4850 W OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7260
Practice Address - Country:US
Practice Address - Phone:954-730-2789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5079103G00000X, 103TC0700X, 103TF0200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650829436OtherTAX ID
FL59639Medicare ID - Type Unspecified