Provider Demographics
NPI:1821203886
Name:WHITLOCK, GAIL LYNN (MSCCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:LYNN
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 EISNER AVE APT G1
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-2974
Mailing Address - Country:US
Mailing Address - Phone:920-458-4904
Mailing Address - Fax:
Practice Address - Street 1:3431 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-2938
Practice Address - Country:US
Practice Address - Phone:920-457-5046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1487-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42757300Medicaid