Provider Demographics
NPI:1922441492
Name:GOTAY, IVELISSE (SLP)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:GOTAY
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 1:1574 BISHOP HOLLOW RUN
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6134
Mailing Address - Country:US
Mailing Address - Phone:561-729-8080
Mailing Address - Fax:
Practice Address - Street 1:4500 SATELLITE BLVD
Practice Address - Street 2:SUITE 2290
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5037
Practice Address - Country:US
Practice Address - Phone:800-381-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001889235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist