Provider Demographics
NPI:1376780833
Name:DISMUKE, GENA S (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:S
Last Name:DISMUKE
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 1:2639 GILMER AVE
Mailing Address - Street 2:
Mailing Address - City:TALLASSEE
Mailing Address - State:AL
Mailing Address - Zip Code:36078-7213
Mailing Address - Country:US
Mailing Address - Phone:334-283-3975
Mailing Address - Fax:334-252-8277
Practice Address - Street 1:245 CAHABA VALLEY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-2216
Practice Address - Country:US
Practice Address - Phone:205-942-6820
Practice Address - Fax:205-942-5884
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL845235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist