Provider Demographics
NPI:1538789250
Name:GWYN, CHRISTINA (SLP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:GWYN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 NATHAN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715-0022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:490 S OLD WIRE RD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-5001
Practice Address - Country:US
Practice Address - Phone:352-748-3683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13576235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist