Basic Information
| Provider Information | |||||||||
| NPI: | 1245505957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNDLACH | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEGSCHEID | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 309 WASHINGTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | ORTONVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394271 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Practice Location | |||||||||
| Address1: | 15620 EDGEWOOD DRIVE | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184547012 | ||||||||
| FaxNumber: | 2184547015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 8722 | MN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.