Basic Information
| Provider Information | |||||||||
| NPI: | 1255940508 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLATLEY | ||||||||
| FirstName: | GILLIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4997 ROYAL GULF CIR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339667006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393135049 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4997 ROYAL GULF CIR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339667006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393135049 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ9649 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 588241575 | 01 | NY | DRIVERS LICENSE | OTHER |