Provider Demographics
NPI:1548735210
Name:GILLMAN, AUDREY LYNN MANALANG (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY LYNN
Middle Name:MANALANG
Last Name:GILLMAN
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 1:9217 BRAYDEN BAY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-9311
Mailing Address - Country:US
Mailing Address - Phone:661-645-3412
Mailing Address - Fax:
Practice Address - Street 1:9217 BRAYDEN BAY ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-9311
Practice Address - Country:US
Practice Address - Phone:650-564-4352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23578235Z00000X
NVSP-2808235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist