Basic Information
| Provider Information | |||||||||
| NPI: | 1417131962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENACHE-RAW | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., M.C.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26 GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | NORTH BROOKFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015351410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044581917 | ||||||||
| FaxNumber: | 9788701846 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | NORTH BROOKFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015351410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044581917 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2007 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | RC00053984 | WA | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.