Provider Demographics
NPI:1669787115
Name:ALLISON, GINA MARIE (LPC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:ALLISON
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:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-1387
Mailing Address - Country:US
Mailing Address - Phone:541-329-0555
Mailing Address - Fax:
Practice Address - Street 1:390 1ST ST SW
Practice Address - Street 2:SUITE 2B
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-4500
Practice Address - Country:US
Practice Address - Phone:541-329-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2507101YP2500X
AK636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional