Provider Demographics
NPI:1629216478
Name:LEE, GINA EASON (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:EASON
Last Name:LEE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-3328
Mailing Address - Country:US
Mailing Address - Phone:731-618-1315
Mailing Address - Fax:
Practice Address - Street 1:1310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3328
Practice Address - Country:US
Practice Address - Phone:731-618-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1658235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist