Healthcare Provider Details

I. General information

NPI: 1245893429
Provider Name (Legal Business Name): GISELE MARIE PATRICK M.A., CCC SP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E FOOTHILL BLVD
ARCADIA CA
91006-2314
US

IV. Provider business mailing address

2475 ADAIR ST
SAN MARINO CA
91108-2611
US

V. Phone/Fax

Practice location:
  • Phone: 626-445-2400
  • Fax:
Mailing address:
  • Phone: 626-390-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP17701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: