Basic Information
| Provider Information | |||||||||
| NPI: | 1003171208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIMRI | ||||||||
| FirstName: | GINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40849 FREMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945384306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106577409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 VICENTE ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941162923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156813211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2012 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1003171208 | 05 | CA | MEDICAID |