Basic Information
Provider Information | |||||||||
NPI: | 1124154778 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOCHACKY-HERBERT | ||||||||
FirstName: | GAIL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2195 JENKS AVE STE A | ||||||||
Address2: |   | ||||||||
City: | PANAMA CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 324054551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505224770 | ||||||||
FaxNumber: | 8507692366 | ||||||||
Practice Location | |||||||||
Address1: | 2195 JENKS AVE STE A | ||||||||
Address2: |   | ||||||||
City: | PANAMA CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 324054551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505224770 | ||||||||
FaxNumber: | 8507692366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA5633 | FL | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 20-2945722 | 01 | FL | ADVANCE REHAB TAX ID | OTHER |