Provider Demographics
NPI:1861568032
Name:VANAELST, GRETCHAN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:GRETCHAN
Middle Name:
Last Name:VANAELST
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:G.G.
Other - Middle Name:
Other - Last Name:VANAELST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:3225 S. MACDILL AVENUE
Mailing Address - Street 2:SUITE 129-333
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629
Mailing Address - Country:US
Mailing Address - Phone:813-486-1116
Mailing Address - Fax:
Practice Address - Street 1:602 VONDERBURG DR STE 201
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:813-654-6644
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA4873235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812005600Medicaid
FL884279500Medicaid
FLS1757OtherBCBS OF FLORIDA