Provider Demographics
NPI:1811986797
Name:GINGERICH, MICHAEL G (LCSW, PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:GINGERICH
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 H ST
Mailing Address - Street 2:SUITE 2N
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-3736
Mailing Address - Country:US
Mailing Address - Phone:707-464-6075
Mailing Address - Fax:707-464-1898
Practice Address - Street 1:550 H ST
Practice Address - Street 2:SUITE 2N
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-3736
Practice Address - Country:US
Practice Address - Phone:707-464-6075
Practice Address - Fax:707-464-1898
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS41541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ10709ZMedicare ID - Type Unspecified