Provider Demographics
NPI:1174783328
Name:CLOUSE, GINA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CLOUSE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 KIMBERLY CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:64034-8700
Mailing Address - Country:US
Mailing Address - Phone:816-808-7216
Mailing Address - Fax:
Practice Address - Street 1:1603 KIMBERLY CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MO
Practice Address - Zip Code:64034-8700
Practice Address - Country:US
Practice Address - Phone:816-808-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009373235Z00000X
MO2009001043235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist