Provider Demographics
NPI:1306228465
Name:GIST, ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:GIST
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 1:1816 MCGEE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-1578
Mailing Address - Country:US
Mailing Address - Phone:817-789-9480
Mailing Address - Fax:
Practice Address - Street 1:1816 MCGEE AVE
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76226-1578
Practice Address - Country:US
Practice Address - Phone:817-789-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111137235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist