Provider Demographics
NPI:1073854519
Name:DVORAK, GILLIAN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:DVORAK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 RANCH VIEW CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-5319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9606 TIERRA GRANDE ST
Practice Address - Street 2:#107,
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-6501
Practice Address - Country:US
Practice Address - Phone:858-695-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16737235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist