Provider Demographics
NPI:1265868848
Name:DIAZ, GINA ROSE
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:ROSE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:ROSE
Other - Last Name:SPACCARELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 W DARES BEACH RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3127
Mailing Address - Country:US
Mailing Address - Phone:443-295-7100
Mailing Address - Fax:301-295-7555
Practice Address - Street 1:135 W DARES BEACH RD STE 102
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3127
Practice Address - Country:US
Practice Address - Phone:443-295-7100
Practice Address - Fax:443-295-7555
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01289231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist