Provider Demographics
NPI:1376199364
Name:GAO, EILEENA (MS)
Entity Type:Individual
Prefix:
First Name:EILEENA
Middle Name:
Last Name:GAO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6233 W BEHREND DR APT 2016
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6926
Mailing Address - Country:US
Mailing Address - Phone:415-867-1100
Mailing Address - Fax:
Practice Address - Street 1:12995 N MARSHALL RANCH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1966
Practice Address - Country:US
Practice Address - Phone:623-486-6450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP12026235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty