Healthcare Provider Details

I. General information

NPI: 1649804048
Provider Name (Legal Business Name): GAYLA ANN IWATA-REUYL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 106
GRESHAM OR
97030-3381
US

IV. Provider business mailing address

24900 SE STARK ST STE 106
GRESHAM OR
97030-3381
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1123
  • Fax: 503-674-1197
Mailing address:
  • Phone: 503-674-1123
  • Fax: 503-674-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number011723
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: