Provider Demographics
NPI:1245979293
Name:GENGARELLA, JUSTINE M (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:M
Last Name:GENGARELLA
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ASHAWAY
Mailing Address - State:RI
Mailing Address - Zip Code:02804-2202
Mailing Address - Country:US
Mailing Address - Phone:401-965-3056
Mailing Address - Fax:
Practice Address - Street 1:18 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ASHAWAY
Practice Address - State:RI
Practice Address - Zip Code:02804-2202
Practice Address - Country:US
Practice Address - Phone:401-965-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist