Provider Demographics
NPI:1528800745
Name:BEACH, GINA L (SLPD, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:L
Last Name:BEACH
Suffix:
Gender:F
Credentials:SLPD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 BAYBERRY LOOP S
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-3465
Mailing Address - Country:US
Mailing Address - Phone:817-994-9409
Mailing Address - Fax:
Practice Address - Street 1:1305 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7640
Practice Address - Country:US
Practice Address - Phone:817-994-9409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS-0921235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist