Basic Information
| Provider Information | |||||||||
| NPI: | 1992863468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | GESSYKA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | M.A., CCC/SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUERRA | ||||||||
| OtherFirstName: | GESSYKA | ||||||||
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| OtherCredential: | M.A.,CCC/SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5130 SAINT MICHAEL AVE | ||||||||
| Address2: | |||||||||
| City: | BELLE ISLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328121139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077015910 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3305 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328066125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078523333 | ||||||||
| FaxNumber: | 4078523301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 02/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA 7117 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 888719500 | 05 | FL | MEDICAID |