Provider Demographics
NPI:1386169324
Name:GEDALLOVICH, ALEXIS VICTORIA
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:VICTORIA
Last Name:GEDALLOVICH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10820 SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-4958
Mailing Address - Country:US
Mailing Address - Phone:954-298-8155
Mailing Address - Fax:
Practice Address - Street 1:16800 NW 2ND AVE STE 301
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5508
Practice Address - Country:US
Practice Address - Phone:786-206-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20116235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist