Provider Demographics
NPI:1346689015
Name:DEMATAS, GINA MARIE (MS, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:DEMATAS
Suffix:
Gender:F
Credentials:MS, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 LINDEN LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1134
Mailing Address - Country:US
Mailing Address - Phone:631-889-1646
Mailing Address - Fax:
Practice Address - Street 1:39 LINDEN LN
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1134
Practice Address - Country:US
Practice Address - Phone:631-889-1646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023689-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03826602Medicaid