Healthcare Provider Details

I. General information

NPI: 1548880107
Provider Name (Legal Business Name): JACQUELINE GELLICK M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C/ RIBERA 23 - 3 IZQDA-DCHA
BILBAO VIZCAA
48005
ES

IV. Provider business mailing address

C/ RIBERA 23 - 3 IZQDA-DCHA
BILBAO VIZCAYA
48005
ES

V. Phone/Fax

Practice location:
  • Phone: 330-416-6511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12268
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2342342
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: