Provider Demographics
NPI:1679268940
Name:GAINES, DESIREE CATHERINE (CCC-SLP/TSSLD)
Entity type:Individual
Prefix:MISS
First Name:DESIREE
Middle Name:CATHERINE
Last Name:GAINES
Suffix:
Gender:F
Credentials: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 1:625 BOLTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2903
Mailing Address - Country:US
Mailing Address - Phone:718-684-6505
Mailing Address - Fax:
Practice Address - Street 1:625 BOLTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2903
Practice Address - Country:US
Practice Address - Phone:718-684-6513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034476235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist