Provider Demographics
NPI:1306379102
Name:MOFFATT, GAIL (MS/CCC)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:MOFFATT
Suffix:
Gender:F
Credentials:MS/CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S ROCK ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2733
Mailing Address - Country:US
Mailing Address - Phone:405-615-1437
Mailing Address - Fax:
Practice Address - Street 1:100 S ROCK ISLAND AVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2733
Practice Address - Country:US
Practice Address - Phone:405-615-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK757235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist