Provider Demographics
NPI:1508816760
Name:DEUTER, GINA RENEA (MCD CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:RENEA
Last Name:DEUTER
Suffix:
Gender:F
Credentials:MCD CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6155
Mailing Address - Country:US
Mailing Address - Phone:870-974-9114
Mailing Address - Fax:870-974-9184
Practice Address - Street 1:2917 KING ST
Practice Address - Street 2:SUITE A
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5322
Practice Address - Country:US
Practice Address - Phone:870-974-9114
Practice Address - Fax:870-974-9184
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139117721Medicaid
AR5U700OtherBLUE CROSS BLUE SHIELD #