Provider Demographics
NPI:1770639908
Name:GOLDEN, GINA CARROLL (SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:CARROLL
Last Name:GOLDEN
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:P.O. DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2109
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:908 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3034
Practice Address - Country:US
Practice Address - Phone:501-847-9711
Practice Address - Fax:501-847-6929
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148257721Medicaid