Provider Demographics
NPI:1558667725
Name:GOULBOURNE, GISELLE CHERISE (SLP)
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:CHERISE
Last Name:GOULBOURNE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:GISELLE
Other - Middle Name:CHERISE
Other - Last Name:MCCALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:842 N HIGHLAND AVE NE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4530
Mailing Address - Country:US
Mailing Address - Phone:404-575-4000
Mailing Address - Fax:404-575-4010
Practice Address - Street 1:1296 CREE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-3167
Practice Address - Country:US
Practice Address - Phone:407-443-6149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007496235Z00000X
COMSSLP.0000014235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist