Provider Demographics
NPI:1295582393
Name:GAVIN, BAILEY JEANNE (AUD)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:JEANNE
Last Name:GAVIN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17900 COUNTY ROAD 40
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MN
Mailing Address - Zip Code:55315-9236
Mailing Address - Country:US
Mailing Address - Phone:952-449-1046
Mailing Address - Fax:
Practice Address - Street 1:1211 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1909
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-283-7381
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1057231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295582393Medicaid