Provider Demographics
NPI:1831737055
Name:GAINES, MONIQUE A (MS, NCC, LPC-IT)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:A
Last Name:GAINES
Suffix:
Gender:F
Credentials:MS, NCC, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 DEER VALLEY RD APT 1
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-4123
Mailing Address - Country:US
Mailing Address - Phone:312-686-5374
Mailing Address - Fax:
Practice Address - Street 1:4513 VERNON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4964
Practice Address - Country:US
Practice Address - Phone:608-236-4460
Practice Address - Fax:608-236-4461
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty