Provider Demographics
NPI:1568768372
Name:OLIVA, GINA M (SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:OLIVA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2206
Mailing Address - Country:US
Mailing Address - Phone:631-831-1028
Mailing Address - Fax:631-648-3442
Practice Address - Street 1:367 SMITH RD
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2206
Practice Address - Country:US
Practice Address - Phone:631-831-1028
Practice Address - Fax:631-648-3442
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14027571235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist