Provider Demographics
NPI:1093598526
Name:GAINES, KEIRSTEN NICOLE
Entity Type:Individual
Prefix:
First Name:KEIRSTEN
Middle Name:NICOLE
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17216 SATICOY ST # 141
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2103
Mailing Address - Country:US
Mailing Address - Phone:818-206-3353
Mailing Address - Fax:
Practice Address - Street 1:13079 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-2575
Practice Address - Country:US
Practice Address - Phone:818-206-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist