Provider Demographics
NPI:1699050062
Name:FIELDS, GINAE MCKINON (SLP)
Entity type:Individual
Prefix:MRS
First Name:GINAE
Middle Name:MCKINON
Last Name:FIELDS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:GINAE
Other - Middle Name:LIVON
Other - Last Name:MCKINON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:481 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-3711
Mailing Address - Country:US
Mailing Address - Phone:817-528-1597
Mailing Address - Fax:
Practice Address - Street 1:481 W 30TH ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-3711
Practice Address - Country:US
Practice Address - Phone:817-528-1597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7696235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist