Provider Demographics
NPI:1629359054
Name:GATES, ALLISON RENAE (MS, SLP)
Entity Type:Individual
Prefix:MRS
First Name:ALLISON
Middle Name:RENAE
Last Name:GATES
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-5405
Mailing Address - Country:US
Mailing Address - Phone:870-866-5251
Mailing Address - Fax:
Practice Address - Street 1:721 W ELM ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-5405
Practice Address - Country:US
Practice Address - Phone:870-866-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP8338235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187968721Medicaid