Provider Demographics
NPI:1952808602
Name:GILBERT-QUISPE-QUEA, RAVEN L (SLP)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:L
Last Name:GILBERT-QUISPE-QUEA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:L
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:3210 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3495
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3210 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3495
Practice Address - Country:US
Practice Address - Phone:989-860-0846
Practice Address - Fax:888-527-3589
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IN46003834A235Z00000X
MI7101008184235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician