Basic Information
| Provider Information | |||||||||
| NPI: | 1902006232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUSTAVSON | ||||||||
| FirstName: | AMIE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 GLEN OAKS CT | ||||||||
| Address2: | |||||||||
| City: | OLD BRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088573503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323136451 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 NEW PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082333720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 41YS00370700 | NJ | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.