Provider Demographics
NPI:1023067998
Name:DETTMORE, GEANINE L (MA,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:GEANINE
Middle Name:L
Last Name:DETTMORE
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 1:1119 SHADOWBROOK TRL
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-6323
Mailing Address - Country:US
Mailing Address - Phone:407-247-8291
Mailing Address - Fax:
Practice Address - Street 1:1119 SHADOWBROOK TRL
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-6323
Practice Address - Country:US
Practice Address - Phone:407-247-8291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7685235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889 365 900Medicaid