Provider Demographics
NPI:1013974641
Name:GORE, ANGELIQUE V (MS)
Entity Type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:V
Last Name:GORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 NW 12 AVE
Mailing Address - Street 2:M851
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-6960
Mailing Address - Country:US
Mailing Address - Phone:305-243-4069
Mailing Address - Fax:305-243-8470
Practice Address - Street 1:1601 NW 12 AVE
Practice Address - Street 2:M851
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33101-6960
Practice Address - Country:US
Practice Address - Phone:305-243-4069
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS2748Medicare ID - Type Unspecified