Provider Demographics
NPI:1164607628
Name:GRULKE, AMY T (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:T
Last Name:GRULKE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2322 W STOTTLER DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2524
Mailing Address - Country:US
Mailing Address - Phone:480-247-9693
Mailing Address - Fax:
Practice Address - Street 1:2248 N ALMA SCHOOL RD STE 102
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2488
Practice Address - Country:US
Practice Address - Phone:480-935-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ412169Medicaid