Provider Demographics
NPI:1679091730
Name:WEISE, GINA FEDERAL (MSP, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:FEDERAL
Last Name:WEISE
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 GRACE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-7485
Mailing Address - Country:US
Mailing Address - Phone:704-661-6456
Mailing Address - Fax:
Practice Address - Street 1:3205 FREEDOM DR STE 7500
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-3490
Practice Address - Country:US
Practice Address - Phone:980-280-6526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6375235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist