Provider Demographics
NPI:1760715593
Name:GOFER, ILONA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ILONA
Middle Name:
Last Name:GOFER
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 1:2339 RIVER PARK CIR
Mailing Address - Street 2:APT. 1511
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4884
Mailing Address - Country:US
Mailing Address - Phone:772-579-8404
Mailing Address - Fax:
Practice Address - Street 1:5800 GOLF CLUB PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-4800
Practice Address - Country:US
Practice Address - Phone:407-299-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 10215235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001410600Medicaid