Provider Demographics
NPI:1033578802
Name:DUFFETT, GINA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:DUFFETT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 MOOSEHEAD DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5242
Mailing Address - Country:US
Mailing Address - Phone:904-304-0109
Mailing Address - Fax:
Practice Address - Street 1:1067 MOOSEHEAD DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-5242
Practice Address - Country:US
Practice Address - Phone:904-304-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13647235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist