Provider Demographics
NPI:1639256381
Name:NUSSBAUMER, TRINA GIDDENS (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRINA
Middle Name:GIDDENS
Last Name:NUSSBAUMER
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 1:1300 CITIZENS BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3965
Mailing Address - Country:US
Mailing Address - Phone:352-323-0612
Mailing Address - Fax:352-787-2386
Practice Address - Street 1:1300 CITIZENS BLVD FL 3
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3965
Practice Address - Country:US
Practice Address - Phone:352-323-0612
Practice Address - Fax:352-787-2386
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 3668235Z00000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812099400Medicaid
FL885297900Medicaid