Provider Demographics
NPI:1699873562
Name:GAIL M VAN TATENHOVE, PA
Entity type:Organization
Organization Name:GAIL M VAN TATENHOVE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN TATENHOVE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP, PA
Authorized Official - Phone:407-876-3423
Mailing Address - Street 1:8322 TANGELO TREE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5437
Mailing Address - Country:US
Mailing Address - Phone:407-876-3423
Mailing Address - Fax:407-876-2120
Practice Address - Street 1:8322 TANGELO TREE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32836-5437
Practice Address - Country:US
Practice Address - Phone:407-876-3423
Practice Address - Fax:407-876-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886506000Medicaid
FL671119796OtherMEDICAID WAIVER