Provider Demographics
NPI:1265664270
Name:GEGENWARTH, MAURA
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:
Last Name:GEGENWARTH
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 1:1439 CAPUCHINO AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3308
Mailing Address - Country:US
Mailing Address - Phone:650-781-2269
Mailing Address - Fax:
Practice Address - Street 1:2015 PIONEER CT STE P2
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1736
Practice Address - Country:US
Practice Address - Phone:510-639-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist