Provider Demographics
NPI:1548880107
Name:GELLICK, JACQUELINE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GELLICK
Suffix:
Gender:F
Credentials:MA, 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:C/ RIBERA 23 - 3 IZQDA-DCHA
Mailing Address - Street 2:
Mailing Address - City:BILBAO
Mailing Address - State:VIZCAYA
Mailing Address - Zip Code:48005
Mailing Address - Country:ES
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:C/ RIBERA 23 - 3 IZQDA-DCHA
Practice Address - Street 2:
Practice Address - City:BILBAO
Practice Address - State:VIZCAA
Practice Address - Zip Code:48005
Practice Address - Country:ES
Practice Address - Phone:330-416-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12268235Z00000X
IL2342342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist