Provider Demographics
NPI:1942482625
Name:DAZA, GINA
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:DAZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:DAZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT INTERN
Mailing Address - Street 1:1615 FRENCH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2475
Mailing Address - Country:US
Mailing Address - Phone:714-824-8140
Mailing Address - Fax:714-824-8141
Practice Address - Street 1:1615 FRENCH ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2475
Practice Address - Country:US
Practice Address - Phone:714-824-8140
Practice Address - Fax:714-824-8141
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health