Provider Demographics
NPI:1306249065
Name:CLEVELAND, GINA MCCANN
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MCCANN
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10126 FRONTIER PL NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9408
Mailing Address - Country:US
Mailing Address - Phone:360-662-1040
Mailing Address - Fax:360-662-1041
Practice Address - Street 1:10126 FRONTIER PL NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9408
Practice Address - Country:US
Practice Address - Phone:360-662-1040
Practice Address - Fax:360-662-1041
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60334049235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist