Provider Demographics
NPI:1215367768
Name:GOLL, CHRISTINE MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:GOLL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9691 SPRING RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-3235
Mailing Address - Country:US
Mailing Address - Phone:239-400-1020
Mailing Address - Fax:
Practice Address - Street 1:14421 METROPOLIS AVE
Practice Address - Street 2:STE 103
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4323
Practice Address - Country:US
Practice Address - Phone:239-561-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist