Provider Demographics
NPI:1174962088
Name:RADICE, GINA M (MA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:RADICE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E HAWTHORN PKWY STE 235
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1454
Mailing Address - Country:US
Mailing Address - Phone:847-737-8768
Mailing Address - Fax:847-859-5885
Practice Address - Street 1:3499 ROUTE 9 N STE 2C
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:847-859-5885
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJR01022887455892103T00000X
NJ35SI00585900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist