Provider Demographics
NPI:1295098549
Name:GILL, LOGAN RAE (SLP)
Entity type:Individual
Prefix:MRS
First Name:LOGAN
Middle Name:RAE
Last Name:GILL
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 1:5633 S STAPLES ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4646
Mailing Address - Country:US
Mailing Address - Phone:361-855-1352
Mailing Address - Fax:361-855-1254
Practice Address - Street 1:5633 S STAPLES ST
Practice Address - Street 2:SUITE 500
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4646
Practice Address - Country:US
Practice Address - Phone:361-855-1352
Practice Address - Fax:361-855-1254
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107861235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist