Provider Demographics
NPI:1346598018
Name:MOUTON, GAIL R (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:R
Last Name:MOUTON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 WAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-1094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 WAKE FOREST DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1094
Practice Address - Country:US
Practice Address - Phone:478-328-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003041235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist