Healthcare Provider Details

I. General information

NPI: 1508816760
Provider Name (Legal Business Name): GINA RENEA DEUTER MCD CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2917 KING ST SUITE A
JONESBORO AR
72401-5322
US

IV. Provider business mailing address

1801 GRANT AVE
JONESBORO AR
72401-6155
US

V. Phone/Fax

Practice location:
  • Phone: 870-974-9114
  • Fax: 870-974-9184
Mailing address:
  • Phone: 870-974-9114
  • Fax: 870-974-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP#1713
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: