Provider Demographics
NPI:1134805070
Name:BORTON, GINA MENUEZ (LLPC)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:MENUEZ
Last Name:BORTON
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MAY
Other - Last Name:MENUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2436 SANTA MONICA DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:330-231-4474
Mailing Address - Fax:
Practice Address - Street 1:2020 RAYBROOK ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-217-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023019101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional